PIJ OF HYDROTHERAPY FOR STUDENTS AND PRACTITIONERS OF MEDICINE Embodying a Consideration of the Scientific Basis, Technique and Therapeutics of Hydrotherapy and some Allied Branches of Physiologic Therapy BY GEORGE KNAPP ABBOTT, A. B., M. D. Dean of Faculty and Professor of Physiologic Therapy and Practice of Medicine in The College of Medical Evangelists Superintendent of The Loma Linda Hospital SECOND EDITION, REVISED AND ENLARGED WITH 128 ILLUSTRATIONS THE COLLEGE PRESS LOMA LINDA, CAL. A Copyright. 1914. by G. K. Abbott Lotna Linda. California PREFACE TO SECOND EDITION HPHE kindly reception given the first edition of HYDROTHER- A APY, in spite of jts many faults, and the requests for a text thoroughly illustrated, have induced the author and pub- lishers to prepare this revised and enlarged edition. The writer more than ever realizes the impossibility of making any text-book a complete treatise, and especially so in therapeutics, the science and art of which are advancing so rapidly. Much new matter has been added, among which are: A chap- ter on Insanity and Drug Addictions, for which the author de- sires to thank Dr. Jessie H. Simpson of the Southern California State Hospital for the Insane; a section on Prescription Writing and Treatment Combinations; and one on Hydrotherapentic Appa- ratus and Treatment Rooms. For conducting an original re- search into the effects of tonic hydrotherapy upon the metabol- ism of individuals on a low proteid diet, the author is indebted to his colleague, Dr. E. H. Risley. Many of the new illustrations have been prepared in the Laboratory of Physiologic Therapy of The College of Medical Evangelists and in The Loma Linda Hospital. For aid in this work the author desires to acknowledge the helpful assistance of medical students, nurses and others, and especially medical students, Wm. Richli and L. D. Trott, in the preparation of drawings and charts. For diagrams and illustrations copied from medical literature we have endeavored to give full credit. For cuts furnished thanks are due to Dr. H. P. Coile, the Hoffmann & Billings Manufacturing Company, James B. Clow & Sons, the Boston Surgical Supply Company, and Mr. A. Campbell. Last, but not least, thanks are diie to The Colleg'e Press for its endeavor to fulfill the wishes of the author in the prepara- tion of a presentable text. Loma Linda, California G. K. A. (i) PREFACE NO apology need be given for the presentation of a work on hydrotherapy. In spite of the advances made in modern physiologic therapy in general, hydrotherapy is still a branch of therapeutics but little used by the general practitioner. The reason is not difficult to find. As a science, it receives but scant attention from teachers of therapeutics, and in the medical curriculum is usually allotted a few hours from the combined course on materia medica and therapeutics, which is already overcrowded by the presentation of a needlessly large number of preparations of doubtful or very limited usefulness. As an art, even less time is devoted to it. It must, however, be acknowledged that this brief consideration is a distinct advance over twenty years ago, when the medical curriculum was quite innocent of even a mention of physiologic therapy. It is the author's firm belief, strengthened by years of experi- ence in the teaching of both medical students and nurses, that the student or practitioner should first acquire a knowledge of the technique of hydrotherapy in the same way that nurses are taught, i. e., by actual drill under an experienced instructor. Insistance upon accurate, personal observation of patients dur- ing their treatment will help to strengthen in the mind of the student the necessity for close clinical observation. In the management of disease, such observation can not be replaced by instruments of precision. In this connection we can not refrain from expressing our opinion that instruction in practical therapeutics and the care of patients should not be left to the later years of the medical curriculum. With this practical knowledge of the visible results to be obtained, the student should devote careful study to the physio- logic and therapeutic effects of each representative class of treatments. This study should include personal laboratory investigation into the effects of thermic and mechanical stimuli upon blood pressure, the heart rate and force, general changes in blood distribution and its cellular composition, muscular (3) 4 PREFACE capacity, and metabolic changes as revealed by chemical exam- ination of the excretions, particularly the urine. In the presentation of the subject, the author has tried to pre- serve the closest connection between experimental physiology and therapeutic deductions and recommendations. We have at all times endeavored to seek out a reason for the results obtained in practice. It is only in this way that varying- conditions may be successfully met. The modern search for "specifics" has greatly aided in the development of scientific medicine. The same principles, how- ever, must not, without modification, be applied to hydro- therapy. Specific results are to be sought by proper adaptation of the treatment to the individual case in hand, rather than by rigid adherence to this or that type of application. For this reason physiologic effects have been dwelt upon quite at length and have been considered apart from the technique. The subject of therapeutics has been presented with a view to the elucidation of basic principles. It is the morbid physio- logic or structural state present in a given disease that requires treatment rather than the "disease" as an entity. Diseases most amenable to hydrotherapy have, therefore, been grouped in classes according to the general principles involved in their treatment , after an explanation of which, each disease is given particular attention. While hydrotherapy is the most important branch of physio- logic therapy, it is not by any means a "cure all. ' ' The border line between physiologic and radical therapeutics can not be drawn by disease lists but must be settled by rational, conscien- tious consideration of the ends to be sought and the trend of the morbid condition in hand. In presentation of this work, the author lays no claims to originality. In addition to personal experience, all available v .urces of information have been drawn upon. The text matter and diagrams are those used by the author in his lectures to medical students. The part on technique is an amplification of a brief treatise on the "Technique of Hydrotherapy" pub- lished by the author in 1908. Loma Linda, Cal. . G. K. A. CONTENTS PART I SCIENTIFIC BASIS AND PHYSIOLOGIC EFFECTS CHAPTER I THE PHYSICAL PROPERTIES OF WATER Communication and Absorption of Heat. Physics of Heat. Calories. Specific Heat. Latent Heat. Thermic Stimuli. Mechanical Stimuli. Solvent and Chemical Properties. Use of Water in all Three States. 17—25 CHAPTER II PRINCIPLES OF EFFECTS AND THERAPY Therapy from Within. Warm- and Cold-blooded Animals. Intrinsic Effects. Reaction. Types and Degrees of Reaction. Conditions Influencing Reaction. Common Names of Tem- peratures. 26—38 CHAPTER III ANATOMY AND PHYSIOLOGY OF THE SKIN Muscular and Elastic Tissue. Blood Vessels. Lymphatics. 39—44 CHAPTER IV THE PERIPHERAL HEART Traube-Hering Waves. Principles of Vascular Effects. Quantity of Circulating' Fluid. 45 — 53 CHAPTER V ANATOMY AND PHYSIOLOGY OF THE SKIN (CONTINUED) Sudoriparous Glands. Summary of Perspiratory Influences. Sebaceous Glands. Absorption by the Skin. Cutaneous Res- piration. The Skin a Heat Regulator. Nerves of the Skin. 54—61 CHAPTER VI THE CIRCULATION— REFLEX EFFECTS Reflex Areas. Reflex Arc. Special Reflex Areas. Classes of Reflex Effects. Special Reflex Effects. 62—77 (5) g CONTENTS CHAPTER VII THE CIRCULATION— HYDROSTATIC EFFECTS Principles of Hydrostasis. Law of Antagonism. Areas for derivation. 78—85 CHAPTER VIII THE CIRCULATION -BALANCE BETWEEN REFLEX AND HYDROSTATIC EFFECTS Laws of Balance. Examples. Double Effects. 86 — 88. CHAPTER IX THE CIRCULATION— BLOOD PRESSURE Force of Heart Beat. Amount of Circulating Fluid. Vascu- lar Calibre and Action. Miiller's Laws. 89—99 CHAPTER X THE CIRCULATION—CHANGES IN COMPOSITION OF THE BLOOD Corpuscular Elements. Mechanism of Distribution. Vis- cosity. Reaction. Practical Application. 100 — 110 CHAPTER XI NITROGENOUS METABOLISM AND EXCRETION Effects of Cold. Nitrogen Economy. Urea and Ammonia. Uric Acid and Purin Bases. Extractives. Phosphoric Acid. Sulphates and Chlorides. Effects of Heat. Effects on Low Proteid Diet. 111—124 CHAPTER XII RESPIRATION, RESPIRATORY CHANGES AND CARBONACEOUS METABOLISM Respiratory Effects. Gaseous Interchange. Carbon Diox- ide. Oxygen. 125 — 129 CHAPTER XIII MUSCULAR CAPACITY Effects of Cold. Effects of Heat. Ergograph and Dynomo- meter Experiments. Fatigue Poisons. Therapeutic Applica- tions. 130—138 CHAPTER XIV THE HEAT MECHANISM Regulation of Heat Production. Regulation of Heat Loss. Experiments in Heat Production and Elimination. Summary. 139—154 CONTENTS 7 PART II THERAPEUTICS CHAPTER xv THE REALM AND LIMITATIONS OF PHYSIOLOGIC THERAPY Functional and Organic Diseases. Natural Means. Radical Means. Basic Principles of Therapy. 155 — 159 CHAPTER XVI FEVERS AND ANTIPYRETIC EFFECTS Causes and Symptoms of Fever. Principles of Treatment. Rationale of Hydrotherapy in Infectious Fevers. Toxic Vaso- motor Paralysis. Medicinal Antipyretics. Antipyretic Effects of Thermic Applications. The Heat Mechanism in Fever. Variations that Produce Fever and Their Relation to Treat- ment. 160—178 CHAPTER XVII THE TREATMENT OF FEVERS Typhoid Fever. Malaria. Measles. Scarlet Fever. Influ- enza. 179—211 CHAPTER XVIII INFLAMMATIONS AND ANTIPHLOGISTIC EFFECTS Depletion. . Fluxion. Revulsion. Pathogenesis of Inflam- mation. Principles of Treatment. 212 — 224 CHAPTER XIX THE TREATMENT OF INFAMMATIONS Inflammations of the Eye. Erysipelas. Otitis Media. Mas- toiditis. Alveolar Abscess. Pharyngitis. Tonsillitis. Boils. Septicemia. Poison Ivy. Pneumonia. Bronchopneumonia. Pleurisy. Pericarditis. Myocarditis. Rheumatic Fever. In- fectious Arthritides. Meningitis. Biliary Inflammations. Appendicitis. Pelvic Inflammations. Phlebitis. Mucous Co- litis. Cystitis. Specific Urethritis. 225—259 CHAPTER XX STIMULANTS AND TONICS Hydriatic Tonics. Anemia. Neurasthenia. Splanchnic Neurasthenia. Hysteria. Dyspepsia. Pulmonary Tubercu- 8 CONTENTS losis. Insomnia. Chronic Inebriety. Chronic Articular Rheumatism. Diabetes. Sunstroke. Valvular Heart Dis- ease. Obesity with Fatty Heart. Excitant and Stimulating- Effects. Uterine, Vesical and Intestinal Stimulants. 260 — 299 CHAPTER XXI SEDATIVE EFFECTS General Sedatives. Pure Sedatives. Tonic Sedatives. Lo- cal Sedatives. Insomnia. Chorea. Paralysis Agitans. Spas- tic Spinal Paralyses. Locomotor Ataxia. Parenchymatous Goitre. The Relief of Pain. Ulcer. Hemorrhoids. Neu- ralgia. Tenesmus. Dysmenorrhoea. Renal and Biliary Colic. Burns. Sprains and Bruises. Fractures. Headache. 300 — 330 CHAPTER XXII EXPECTORANT EFFECTS Colds. Acute Coryza. Acute Bronchitis. Croup. Asthma. Chronic Bronchitis. 331 — 336 CHAPTER XXIII DIAPHORETIC AND DIURETIC EFFECTS Diaphoretic Effects. Diuretic Effects. 337-340 CHAPTER XXIV SYSTEMIC AND METABOLIC DISEASES Obesity. Icterus. Systemic Poisoning-. Internal Conges- tions. Gout and Gouty Rheumatism. Bright's Disease. Uremia and Eclampsia. 341—362 CHAPTER XXV PEPTOGENIC EFFECTS Atonic Dyspepsia. Gastrectasia. Hypochlorhydria. Hyper- chlorhydria. 363—369 CHAPTER XXVI HEMOSTATIC EFFECTS Epistaxis. Pulmonary Hemorrhage. Gastric Hemorrhage. Ltenne Hemorrhage. Apoplexy. 370—372 CHAPTER XXVII HYDROTHERAPY IN SURGERY Preparatory Treatment. Immediate Car,. Surgical Shock. CONTENTS 9 Vasomotor and Cardiac Changes. Hydriatic Treatment of Shock. Drug- Treatment of Shock. After Treatment. 373— 393 CHAPTER XXVIII INSANITY AND DRUG ADDICTIONS Mania. Depressed Cases. Morphinism. Alcoholism. 394 —396 PART III TECHNIQUE OF HYDROTHERAPY CLASSIFICATION OF PROCEDURES AND GLOSSARY OF TERMS Basis of Classification. Definitions. 397 — 400 LOCAL APPLICATIONS OF HEAT Fomentations. Hot Compress. Stupes. Alternate and Simultaneous Hot and Cold Treatments. Hot -Water Bottles. Hot Water Coil. Radiant Heat. 401—409 LOCAL APPLICATIONS OF COLD Cold Compress. Ice Pack. Ice Cravat. Ice Bag-. Cold Water Coil. 409—412 HEATING COMPRESSES Moist Chest Pack. Dry Chest Pack. Moist Abdominal Ban- dage. Heating Throat Compress. Heating Joint Compress. Medicated Compresses. 412 — 417 POULTICES White Clay and Glycerine. Charcoal. 417 — 418 TONIC FRICTIONS Cold Mitten Friction. Wet Hand Rub. Cold Towel Rub. Wet Sheet Rub. Dripping Sheet Rub. Ice Rub. Salt Glow. 418—423 SPONGING Hot, Cold and Tepid Sponge. Saline Sponge. Alkaline Sponge. Vinegar and Salt Rub. Alcohol Rub. Witchhazel Rub. Menthol Rub. Soap Wash. 423—425 RUBS AND FRICTIONS Centripetal Friction. Oil Rub. Talcum Rub. Dry Fric- tion. 425—430 w CONTENTS BATHS Partial Immersion. Hand and Arm Bath. Foot Bath. Leg Bath. Sitz Bath. Hot Half Bath. Full Immersion Baths. Hot, Cold and Neutral Tub Baths. Brand Bath. Graduated Bath. Cold Shallow Bath. Hydro- Electric Baths. Medicated Baths. Nauheim Bath. Oxygen Bath. Russian Bath. Vapor Bath. Turkish Bath. Superheated Air Bath. Electric Light Bath. 430—452 SHAMPOOS Swedish Shampoo. Tub Shampoo. Turkish Shampoo. 452 —454. PACKS Full Hot Blanket Pack. Dry Blanket Pack. Trunk Pack. Pelvic Pack. Hip and Leg Pack. Hot Packs with Ice Bags. Electro-thermal Pack. Evaporating, Neutral, Heating and Sweating Wet Sheet Packs. Heating Trunk Pack. Hot and Heating Trunk Pack. Heating Pelvic Pack. 454—467 SPRAYS AND DOUCHES Shower Bath. Spray Bath. Revulsive, Alternate, Percus- sion and Spray Douches. Spray and Douche Prescriptions. Affusions. Pail Pour. 467—476 ENEMATA Hot, Cold and Graduated Enemata. Cold and Alternate Rectal Irrigation. Coloclyster. Saline Enema. Proctoclysis. Soapsuds, Oil, Asafoetida, Glycerine and Epsom Salts, Starch, Astringent, Quassia, Quinin Enemata. 476 — 486 VAGINAL IRRIGATION Hot, and Alternate Hot and Cold Vaginal Irrigation. Dis- infectant and Styptic Vaginal Irrigation. 486—489 PRESCRIPTION WRITING AND TREATMENT COMBINATI NS General Rules, Illustrations and Prescriptions. 490 — 494 HYDROTHERAPEUTIC APPARATUS AND TREATMENT ROOMS General Treatment Rooms. Fomentation Tank. Steam Leg Tubs. Foot Tubs. Bath Tubs. Sitz Tubs •tectric Light Cabinets. Russian and Turkish Bath Rooms. Enema and Douche Outfit. Spray and Douche Con- troller. Douches. 495 510 ILLUSTRATIONS PLATES PLATE OPP. PAGE Frontisplate, Reflex arc from skin to heart I Diagrammatic section of skin 40 II Visceral sympathetic nerves 62 III The innervation of the heart 68 IV The effect of baths on blood pressure 98 V Portable tub on wheels 182 VI Portable tub with raising device 182 VII The Coile bed bath 186 VIII Continuous cooling in typhoid fever 186 IX Sudorific treatment in influenza 210 X Depletion by simultaneous heat and cold 212 XI Hot and cold immersion for infected hand 232 XII Fomentations to chest for pleurisy 246 XIII Ice pack to knee in acute arthritis 250 XIV Fomentations to knee in chronic arthritis 250 XV Local superheated air bath, preparing 348 XVI Local superheated air bath, using 348 XVII Hot air bath in bed 356 XVIII The Winternitz pack with hot water coil 366 XIX The Winternitz pack with hot-water bottle 366 XX The continuous flowing bath 396 XXI The sedative wet sheet pack 396 XXII Wringing a fomentation by hand 402 XXIII A fomentation tank with wringers 402 XXIV Steam boxes for heating fomentations, closed 404 XXV Steam boxes for heating fomentations, in use 404 XXVI Hot-water bottles 408 XXVII Ice bags 408 XXVIII Square chest pack, roller chest pack, and moist abdominal bandage 412 XXIX The roller chest pack, applying 414 XXX The roller chest pack, finished 414 (a) ILLUSTRATIONS XXXI XXXII XXXIII XXXIV XXXV XXXVI XXXVII XXXVIII XXXIX XL XLI XLII XLIII XLIV XLV XLVI XLVII XLVI 1 1 XLIX L LI LII LIII LIV LV 416 416 418 418 420 422 422 436 436 448 The square chest pack, applying- The square chest pack, finished The moist abdominal bandage The cold towel rub The cold mitten friction The wet sheet rub, applying the sheet The wet sheet rub, rubbing the patient The sitz bath The hot half bath The Russian bath room, in use The Russian bath room, open, showing shower 448 The Turkish bath cabinets . 450 Superheated air bath, ready for use 450 Superheated air bath, patient in Turkish towel- ing suit 450 Superheated air bath, in use 450 Electric light bath cabinet, upright form 452 Electric light bath cabinet, horizontal form 454 The hot blanket pack 460 The evaporating wet sheet pack 460 The author's hydrotherapy control table 468 A seepage apparatus 484 Continuous proctoclysis 484 Adjustable standard for enema and douche cans 502 Enema cans arranged for alternate hot and cold rectal irrigation 502 Rectal and vaginal tubes 502 TEXT FIGURES FIGURE 1 2 3 4 Expansion of water at different temperatures Comparative thermometer scales Chart of wave energies Diagram illustrating time factor in intrinsic and reac- tionary effects Origin of lymphatic vessels in a papilla of the hand (Sappey) Superficial lymphatics of the arm (Sappey) Valves of mc-senteric ehylifcrous vessels (Delamere) PAGE ILLUSTRATIONS 13 8 Blood pressure tracing-, showing: Traube-Hering' curves taken from a dog under artificial respiration 46 9 Blood pressure tracing, showing Traube-Hering curves taken from a dog" after cessation of respiration 46 10 Rhythmical vasomotor waves of blood pressure in a dog- 47 11 Tone waves in heart muscle 48 12 Periodic fluctuations in blood pressure tracing taken from man at rest 49 13 Diagram of glomerulus and uriniferous tubule 55 14 Diagram of coil gland of skin and vascular network 55 15 Diagram to show vasomotor reflex arc (Howell) 66 16 Anterior reflex areas (Kellogg) 70 17 Sphygmograph tracing- showing- effect of proximal ap- plication, on pulse wave (Kellogg) 74 18 Plethysmographic tracing- showing- effect of proximal application on volume curve (Kellog-gO 74 19 Diagram showing- congestion of lungs 75 20 Diagram showing reflex action of ice bag- on cong-ested lung 75 21 Volume curve of rig'ht arm during- a hot sitz bath, showing derivative effect (Winternitz) 80 22 Volume curve of right arm during cold sitz bath, show- ing retrostatic effect (Winternitz) 81 23 Curve showing effect of a sudden rise in the arterial resistance on the output and volume of the ventricles (Starling-) 90 24 Cardiometer tracing showing effect of increasing the volume of circulating fluid on the total output and volume of the heart (Roy) 91 25 Faught's sphygmomanometer 96 26 Riva-Rocci sphyg-momanometer 97 27 Gartner's tonometer 98 28 Chart showing- effect of cold on blood count and hemo- globin 101 29 Plethysmographic tracing of spleen, showing the spon- taneous rhythmical contractions of this organ (Howell) 104 30 Chart showing effect of thermic procedures on alka- linity of blood 106 n ILLUSTRATIONS 31 Chart showing effect of thermic procedures on acidity of urine 32 Curve showing effect of cold treatment on fecal and urinary nitrogen (Strasser) 33 Curve showing effect of cold treatment on urea, phos- phates and ammonia (Strasser) 34 Curve showing effect of cold treatment on the oxida- tion of purins (Strasser) H7 35 Curve showing effect of cold treatment on the alka- line and earthy phosphates (Strasser) 36 Mosso's ergograph 37 Ergograms showing effect of cold bath on muscular capacity 13- 38 Ergograms showing effect of graduated bath on mus- cular capacity 133 39 Ergograms showing effect of graduated bath on fa- tigue 133 40 Ergograms showing effect of cold wet sheet rub on fatigue 134 41 Ergograms showing effect of warm bath and warm douche on fatigue 134 42 Tracings showing effect of caffeine on voluntary muscle (Wood) 136 43 Rubner's chart showing manner of heat loss at differ- ent temperatures 143 44 Diagram illustrating heat regulating mechanism (Wood) 145 45 Reichcrt's water calorimeter 146 46 Chart showing effect of physical measures on heat elimination (Winternitz) 149 47 Diagram showing quantitative relation between tem- perature-raising and temperature-lowering capacity of different treatments 173 48 Burr portable bath" 181 49 Maragliano's chart of temperature and peripheral vasoconstriction in malaria 201 Capillaries as affected by irritant and inflammation < Brunton) 218 51 A pparatns for treating inflammations of eye 226 The window tent for the fresh air treatment of fevers 235 V> The perineal (louche 258 ILLUSTRATIONS 15 54 Diagram showing" dynamic conditions in valvular heart disease 284 55 Physical chart of heart and liver as affected by Nauheim bath and tonic hydrotherapy 290 56 Diagram to show the effects of heat and cold in lessen- ing the pain of inflammation 304 57 Inhaler for medicated steam (Kellogg) 334 58 An improved croup kettle (Dieffenbach) 335 59 Three sizes of radiant heat 408 60 The Winternitz coil 411 61 Plan of fomentation tank 497 62 Steam coil for heating fomentation water, obverse 498 63 Steam coil for heating fomentation water, reverse 498 64 Plan of steam box 499 65 Molasses faucet outlet for leg tub 500 66 Flume gate outlet for leg tub 500 67 Plan of top of control table 504 68 Martinson mixer, showing its construction 505' 69 Niedecken mixer, showing working parts 506 70 The jet douche, the spray douche, the fan douche 507 71 Plan of seat spray for the perineal douche 508 72 Wall control, showing front and side elevation plans 509 CHAPTER I THE PHYSICAL PROPERTIES OF WATER IN the application of any therapeutic agent, it is essential to obtain an understanding of those properties of the agent itself, of which particular use is made in the treatment of dis- ease. In the case of water, these essential properties may be discussed under the following heads : — 1. Its ability to comnmnicate and absorb large quantities of heat by contact. (a) Specific heat. (£) Latent heat. 2. Its great temperature-conducting capacity — thermic stimulation . 3 . The perfect flitidity of water — its use in mechanical stimulation . 4. Its solvent properties and use in nutritive and metabolic changes. 5. Existence of water in the three states of matter within a short range of temperature — practicability of applying it to the body in all these three states. 1. The Communication and Absorption of Heat. Hydrother- apy consists chiefly in the application of heat and cold to the body by means of water. Its most helpful results are obtained from the heat applied. In its most scientific and practical phases it is a study of thermotherapy. This being true, in the power of water to communicate and absorb large quantities of heat, without itself undergoing a corresponding" change in tem- perature, lies its most useful property. To rightly apply so powerful an agent, one should understand the physics of heat as it applies to water. A brief summary of this subject will not, therefore, be out of place. 2 (17) IS PROPERTIES OF WATER PHYSICS OF HEAT When heated, the particles of any substance separate slightly, thus moving more freely upon each other when hot than when cold. Solids are thus made softer, more porous, and pliable. With some solids this is so marked that they may be moulded into various shapes even before hot enough to become liquids. The body tissues are likewise made soft and pliable through the influence of heat. The skin is expanded, the muscles relaxed, and the blood-vessels dilated. 4. 3 V\K. 1. Expansion of water at temperatures from 0° C. to 100° C. In general, heat expands all substances, some, however, to a greater degree than others. Each metal, for example, shows a definite degree of increase in bulk when heated. Water ex- pands, occupying more space as its temperature increases above 4 C. (39.2° F.). Nearly all substances continue to contract indefinitely under the influence of cold; /. i temperature. 2. Temperature-Conducting Capacity of Water — Thermic Stimuli. It might, on first thought, seem that a thermic stim- ulus is identical with the communicating of heat. It, however, does not depend upon the amount of heat communicated to or absorbed from the body, but rather upon the impression MECHANICAL STIMULI 23 made upon the nerves. In this respect the temperature of the body, or rather, that of the skin, may be said to be the zero of the temperature sense. Water of a temperature above this, creates an impression of heat, while water below this temper- ature gives a sensation of cold. A brief application of ice may give a sensation of cold as intense as one of longer duration. On the contrary, to abstract heat from the body to any appre- ciable extent, the application must be more or less prolonged. These thermic stimuli are of the greatest value in hydrother- apy; we may say, equally so with the actual transfer of heat. Here, also, the thermic capacity of water makes it of inestim- able value. ' The temperature -conducting capacity of water is twenty-seven times greater than that of air. Water conveys to the skin much stronger thermic impressions than does air at the same temperature, a fact easily discovered in exchanging a room temperature at 75° F. for a tub bath at the same tem- perature. ' ' And again, the accuracy with which we may regulate the temperature of hydriatic applications and so gauge the thermic impressions as well as the heat communicated or absorbed, makes it doubly convenient and valuable. 3. Perfect Fluidity of Water — Mechanical Stimuli. The con- venience with which water lends itself to the application of various mechanical stimuli is due to its most apparent physi- cal property— fluidity. Because of this perfect fluidity, its application can be controlled to a nicety not possible with other agents. With the proper appliances, the amount and temper- ature can be accurately gauged. The size, form, character, and pressure of douches, sprays, and pours can be varied to suit the varying needs of a great variety of cases. It is these four fac- tors that govern the mechanical effect in the class of treat- ments mentioned. Water may be applied under very great pressure, thus enhancing the thermic effects, or it may be applied with little or no pressure. Not only may water itself be used to apply percussion, but its application may be advantageously combined with percussion and friction from other sources, as in the wet hand rub or cold 1 Baruch— Principles and Practice of Hydrotherapy, p. 31. t4 PROPERTIES OF WATER mitten friction. In this case it is the bare hand or rough mit- ten that is the chief source of friction. The Brand or cold rub- bing bath is another example of this combination of mechanical and thermic stimuli, each enhancing- each. It must not be sup- posed, however, that the marked effect of this form of bath is due merely to a combination of the thermic and mechanical stimuli. It is necessary that water be used. Apropos of this question, we quote the following from Baruch: "We would again insist upon the fact that neither in typhoid nor in cardiac inadequacy, can these effects, or anything like them, be pro- duced by cold alone (for that has been thoroughly tried in both cases), by the temporary application of water alone, of what- ever temperature, or by either dry saline or gaseous or mech- anical irritants. It is absolutely necessary that, not merely cold, but cold water should be used, that the surface should be literally rubbed with this for a considerable length of time." -' The same may be said of the cold mitten friction. The aston- ishing results of this procedure can be obtained, neither by the application of cold alone nor by friction with the dry mitt. It is only by vigorous rubbing with the mitt, dipped in cold water, that the maximum effects are produced. 4. Solvent and Chemical Properties. That these properties are of less importance than the preceding will be granted by those familiar with hydriatic measures. The solvent properties of water are utilized in the shampoo, enema, etc. Its value as a solvent in the processes of osmosis and dialysis are likewise made use of in hypodermoclysis and saline enemata. As a means of combining thermic and chemical stimuli, it is used as a solvent in the Xauheim or effervescent bath, saline baths, etc. Internal Hydrotherapy. Going a little further from the physi- cal into the chemical activities, and almost outside of tin- range of hydrotherapy, unless it be in water-drinking, we may consider water in its relation to the nutritive and metabolic pro- cesses of the human body. It is the medium of all commerce and exchange in the carrying of nutrition to the tissues, and wastes from them to the excretory organs. It constitutes 75 per cent of the body weight. Without it life would be impos- 2 Baruch— Principles and Practice of Hydrotherapy. p. 12. WATER IN THREE STATES 25 sible. Not only is it concerned in the mere physical inter- change of nutrient and waste substances, but it is actually necessary in by far the greater number of all chemical changes which these substances undergo. Many body wastes are but sparingly soluble, and for this reason require large amounts of water to hold them in solution. The flushing of the system consequent on free water-drinking is, therefore, one of the greatest of all aids to elimination. 3 The popular belief that particular virtue resides in the min- eral constituents of water used for hydrotherapeutic purposes is almost wholly erroneous. This is rarely the case and is con- fined to a very few procedures such as the Nauheim bath above mentioned. The treatment of rheumatism and obesity at vari- ous hot springs derives but little advantage from minerals pres- ent in the water (unless it be that " faith " in these induces the patient to drink more water than usual). The results are due to the thermic effects of the hot water, combined with regulation of diet and copious water-drinking. Balneology — the use of mineral waters in the treatment of disease, therefore, adds little or nothing to the science of hydrotherapy. 5. Use of Water in Solid, Liquid, and Gaseous States. No other substance, capable of such diversified utility as water, exists in all the three states of matter in such a short range of temperature. The change from the solid through the liquid to the gaseous state is accomplished in a range of 180° F. (100° C.). Not only is this true, but it also changes readily from one form to another. It is possible to apply water to the body in any of these forms; even the application of the two ex- treme forms — ice and steam — is of practical utility. The ice bag is an indispensable adjunct to a great variety of treatments. The ice rub has also been mentioned. The use of Russian and similar vapor baths is well known. The steam douche has also acquired some degree of reputation as a therapeutic agent in certain conditions. This practicability of employing water in all three, states of matter and its ready change from one to another within a comparatively short range of temperature, greatly enhances its utility as a therapeutic agent. 3 See Chapter XI, Hawk's observations. O w u fa o o (26) ^ A — • * t* . <\ o I UJ £o ouipu] < O«O 1VANOSJJVQ 5 U >*'a S «' ^, 52 r- « •*-> v- ?*J^ c QO g<->w >- * g£.w -A *4-l CB Oft O1^* " M Ml ^ , f , 2'. i- •*-> r^ ?r ** o-c o nijs-j; o to <* C 4) &,c g o $ tl 5«jg'dS§1i 2 42 +3 bc« J3 E £ & K "o "^ *d 4> *• c &-H CHAPTER II PRINCIPLES OF EFFECTS AND THERAPY THE basic principles of hydrotherapy are found chiefly in an explanation of the effects of heat and cold. Viewed in this light, the science is that of thermotherapy. Effects similar to those produced by thermic impressions can be obtained by sunlight, friction, percussion, and in fact, all physiologic agents. This is most notably true of light, many of the physiologic effects of which run parallel with those of hydrotherapy. In fact, thermic and actinic energies are so closely related that they overlap each other in the visible spectrum (Fig. J.). From the lowest limit of the scale of energies, up through electric energy, heat, light, and actinic rays to radium emanations and the X-ray, there is laid out before the physician a greater supply of efficient curative means than can be found anywhere else in the whole realm of therapeutics. THERAPY FROM WITHIN Those agents which, by their toxic action, arouse the body to resist their intrusion, can not be classed as physiologic means. They excite abnormal and unusual activities which are largely directed against the toxic agent itself, rather than heightening the normal activities which keep the body in health and repel the onset of morbid processes. Merely to relieve temporarily a distressing condition, without enabling the body itself to over- come that condition, is doing no permanent good. The sick can not always be applying special means. After recovery, they must depend upon the natural surroundings and ordinary agen- cies which keep the body in health. For example, to relieve pain by cocaine, an ice bag, pressure, or a fomentation is pro- (27) t8 PRINCIPLES OF EFFECTS AND THERAPY ductive of no lasting good, unless that cocaine, ice bag, press- ure, or fomentation causes the body to overcome the condition producing- the pain; and its repeated application brings about such a change that the pain (or diseased condition) does not reappear after the curative agent is withdrawn. The body must be made to ' ' cure ' ' itself. The restorative power lies in nature. The natural God-given forces must be rejuvenated. The power from without must produce or arouse power from within. WARM- AND COLD-BLOODED ANIMALS The reason that thermic applications and impressions are so powerful in arousing body functions lies in the fact that life activities are carried on only within a certain limited range of temperature. With regard to body temperature, there are two general classes of animals, viz., the warm- and the cold-blooded. The temperature of so-called ' ' cold-blooded ' ' (poikilother- mic) animals rises and falls with their surroundings. The organism is not injured by comparatively wide variations. The frog, for example, is lively in water at 70° F., and sluggish in water at 45° F., but it nevertheless lives and remains nor- mal in either. These variations do not seriously depress vital activities. The organism is able to withstand such radical changes in the temperature of its blood and body generally, without this change being inimical to its life. The body tem- perature of these animals remains slightly above that of the cold water they may be in and slightly below that of warm water. Cold-blooded animals are principally aquatic and amphibian. Certain other animals maintain a constant temperature under varying conditions. The surrounding air, whether hot or cold, does not materially alter their body temperature. ' The heat mechanism is so nicely adjusted that more heat is produced when the surrounding medium is cold, and less when the air or other medium is hot. This class of animals is called "warm- blooded " (homeothermic) because of the constant temperature at which their blood is kept. Arterial blood is slightly warmer than venous. The ordinary limits for man are about 101° — 103° F. INTRINSIC EFFECTS 29 Organs of constant activity, such as the heart, liver, and brain have a temperature 2° — 4° higher than the average of the blood stream. At ordinary room temperature, the uncovered skin has a temperature of from 92° — 95° F. This fact is of importance in the administration of neutral baths. The water should be 1° or 2° higher than that of the general skin tempera- ture. This secures a full sedation by adding a slightly relaxing effect. As noted above, the internal temperature of warm- blooded animals is comparatively a fixed point, or varies within only very narrow limits, not more than one degree in health. Any radical or prolonged departure from this fixed point (98.6° F. by mouth) interferes with vital functions. INTRINSIC EFFECTS When the body becomes thoroughly chilled, as by a long ride in the cold, the pulse and respiration are slowed, the circulation is less rapid, the nerves benumbed, the muscles respond slug- gishly and clumsily, the finer skilled movements are impos- sible, digestion is retarded, the body temperature is lowered. Cold is, therefore, in itself, a vital depressant, i. e., it retards vital processes. This is its intrinsic effect. Kellogg records an experiment in which immersion of the body in water at 55° F. for ten minutes reduced the pulse rate from seventy-six to fifty per minute. Another, in which twenty minutes in water at 45° F., the patient being rubbed continuously, re- duced the pulse rate from eighty to fifty-eight. Both experi- ments were upon healthy persons. In another experiment ex- posure to cold showed tactile sensibility decreased. Before the exposure the points of an esthesiometer were detected as two separate points at a minimum separation of 2 mm. After five minutes immersion in water at 40° F., the minimum distance was increased to 6 mm. Another, in which five minutes in water at 68.4° F., reduced the body temperature 0.8° F. These data serve to make definite, facts with which we are acquainted in a general way only. It will be seen from this that an overactive process may be retarded and brought back toward the normal by an application of cold, continued until its intrinsic effects are manifest. The SO PRINCIPLES OF EFFECTS AND THERAPY longer the duration of the cold application, the greater its effect. The same is true of the degree of cold. The lower the temperature, the more pronounced the effects. While cold retards, heat stimulates vital activities. We know what it is to experience the vivifying effects of the warmth from a fire or sunlight after being in very cold air for some time. The circulation is quickened; the heart beats faster; respiration is more rapid; nerve sensibility is heightened; muscular action is quicker, more certain, and precise; and digestion proceeds more rapidly. In watching the activity of the white blood cell under the microscope, the stage must be kept warm or the movements will cease. The amoeba, paramoecium, and other one-celled animals exhibit their peculiar movements only in the presence of a certain amount of heat. When cold, their move- ments cease entirely. Cold, per se, decreases oxidation and metabolic activities; heat increases the oxidizing capacity of the tissues and metabolic activities are hastened. When the body is overheated its functions are abnormally increased and, if long continued, permanent injury may result. When heated only to a slight degree, however, sluggish activi- ties are whipped up and, if the applications of heat are repeated at intervals, the retarded functions tend to return to normal. REACTION The most interesting and phenomenal results of hydrotherapy are due to that complex process — reaction, i. e., the part which the body itself takes in its own recuperation and healing. This interesting phenomenon, in its entirety, is observed only in homeothermic animals. Cold-blooded animals, instead of re- acting to their external medium, are subject to the vicissitudes of their environment. On the contrary, warm-blooded animals maintain more or less uniformity of function because of the per- fect control exercised over vital processes by the nervous system. This control is more highly developed and complicated than in poikilothermic animals. We have seen that the influence of cold is to depress vital activities; that is, if continued long enough, its intrinsic effect is manifest in depression. But let us notice the effects of a REACTION SI £r/. /2.) by Mosso, taken from a man at rest, in which the Traube-Hering wave covers on an average of fifteen pulse 5 Clinical Study of Blood Pressure, pp. 112, 113; s?e also pp. 16—21. VASCULAR EFFECTS 49 waves, thus showing- a fluctuation recurring about four or five times a minute. Events occurring in other parts of the body may give rise to large changes, so that the arterioles may become constricted almost to obliteration, or dilated to more than double their usual diameter. These observations apply to arteries, capil- laries, and veins. In the vessels of the web of a frog's foot, direct treatment of the web may bring about the same changes. Since these rhythmic vascular changes normally occur quite independently of the heart beat, we have here a factor in the circulation which, under proper physiologic stimulation, may be utilized to relieve that organ of much of its work, so that Pig. 12. Periodic fluctuations in the tracing of blood pressure taken from Doctor Colombo (at rest). (Mosso s sphygmograph.) when overburdened, it may obtain needed rest through the slowing of the rate and the increasing of the force consequent upon this help. Landois,6 in discussing blood pressure as altered by changes in the size of the vessels, mentions the application of heat and cold to circumscribed areas as influenc- ing blood pressure through the vasomotor nerves. It is to the applications which bring about such changes as these that we now turn our attention. THE PRINCIPLES OF VASCULAR EFFECTS The underlying principle of applications calculated to awaken an activity of the circulation is found in the old dictum, ubi ir- ritatio, ibi affuxus. Where there is an irritation, there is an 6 Human Physiology, p. 166. 50 THE PERIPHERAL HEART afflux of blood. Rub vigorously the back of the hand and the skin becomes reddened with an increase of blood. Percussion or a dash of cold water produce the same results. These are examples of what we may term physiologic irritation. All forms of irritation produce an initial contraction of the blood-vessels, ; . e. , the primary effect of an irritation from any source is con- traction. The oscillatory changes which soon result (reaction) are different with the different kinds of irritation. In fact, it is this reaction with which we are principally concerned. In some cases the first effect is of no practical importance, while in others, it is utilized. Heat, for example, causes an initial vaso- constriction. The secondary vascular contractions are slight and. become less and less the greater the duration of the appli- cation, so that a prolonged application of heat results in a maxi- mum dilatation. The remote effect is not a reddening of the skin from quickened circulation, but a slight duskiness from stasis of blood (passive hyperemia). These are the effects of a fomentation, heating compress, radiant heat, etc. The reaction to heat is, therefore, of an atonic and depressing nature. With a cold application to the skin, the first effect is a blanch- ing (vasoconstriction), but this is soon followed by a reddening (active hyperemia) which, as we know, is maintained for a con- siderable length of time and does not result in a dusky color. Here, the oscillations in vascular calibre are stimulated in such a way that they are greater, more forcible and do not tend to passive dilatation. This is the reactionary effect of cold. Me- chanical irritation, such as friction and percussion, give similar results. However, the two combined, as in the cold mitten fric- tion, cold percussion douche, etc. , give quicker, better, and more lasting effects. Kellogg 7 records the following experiment as showing the ad- vantage of mechanical irritation combined with cold. A cold compress and a percussion douche, both at 65° F., were simul- taneously administered to opposite and corresponding parts for five seconds. After the cold compress the reaction appeared in forty seconds, whereas, after the cold percussion douche, the circulatory reaction appears in five seconds. 7 Rational Hydrotherapy. 1901. p. 1126. VASCULAR EFFECTS 51 As the cold application is prolonged, the amplitude of the vas- cular oscillations becomes less and less until the condition is more nearly that of a constant vasoconstriction. "Following the process to an extreme point, we find that, by intensely low temperatures, the circulation in the capillaries is at first accel- erated and the number of blood corpuscles diminished, when the part becomes pale. Quickly following this acceleration there is a stasis in the capillaries, while in the smaller veins and arteries, the slowing of the circulation is followed by brief and rapid oscillations, which become slower and more infrequent. Slowly the vessels become more pale, less transparent, and finally the movements cease." This is, of course, providing reaction occurs at all, as it usually does if the cold is applied to a limited area. If the reaction does not occur, as where there is a general application of cold without friction, the skin be- comes blanched and goose flesh appears, due to the contraction of the erectores pilorum. In case an ice-cold application re- mains long enough on one part, paralysis of the vessels results and a consequent dilatation. Saline substances and certain gaseous irritants, chief among which is COa, when applied to the skin, also produce an active dilatation and contraction of the blood-vessels which results in quickened circulation and increase of blood in the skin. Saline baths are often more effective than plain water. Carbon dioxide and salines are most effectively used in the combination consti- tuting the Nauheim or effervescent bath. Here the cool water itself plays some part, since temperatures somewhat below neu- tral are used. " So marked is the effect of this skin tonic that in severe cases of dilatation (of the heart) the almost incredible result is attained, of causing the apex actually to retract three quarters of an inch toward its normal position in a single treat- ment." The heart beat is decreased in frequency and in- creased in force; its previously labored beat gives way to a steady, easy movement and, in some cases, we have actually been unable to detect murmurs which were previously distinctly heard. These results are by all conceded to be due chiefly, if 8 Baruch— Principles and Practice of Hydrotherapy, p. 39. 9 Baruch— Ibid., p. 10. 5g THE PERIPHERAL HEART not almost wholly, to the stimulation of the great vascular area of the skin, the so-called " peripheral heart " or " skin heart." When we consider the magnitude of this peripheral heart, it no longer becomes a wonder that its influence is so powerful. Yierordt estimates the combined calibres of the capillaries of the systemic circulation at 800 times that of the aorta in cross sec- tion. With this fact in mind, we may gather some idea of the magnitude of the effect produced by saline and gaseous irritants acting simultaneously upon such a great system of contractile tubes. Such results can not be obtained by digitalis or strych- nine. That these results are not due to simple atonic vasodila- tation is shown by the fact that these patients are frequently cyanotic, an evidence of already existing venous stasis and vaso- dilatation, while on emerging from the bath, the skin is of a brighter and more normal color. Neither vasodilatation nor vasoconstriction are conducive to a slower, easier heart beat. The result is, therefore, not a passive change, but an active one. Electric currents applied to the skin also stimulate the vaso- motors. Near the positive pole vasoconstriction is manifest, while in the region of the cathode vasodilatation occurs. With alternating or interrupted currents the vasomotors are much more powerfully stimulated. This stimulation is greatest with the sinusoidal current, the use of which in the obtaining of vas- cular effects will be mentioned more in detail in the part on therapeutics. THE QUANTITY OF CIRCULATING FLUIDS When we consider the total quantity of blood and lymph in the body, and the fact that the skin and adjacent tissues may con- tain a large share of this, or influence its distribution elsewhere, we see how powerful an agent the skin is in controlling the cir- culation of these fluids in the various organs. About one-thirteenth of the body weight is blood. Of this, nearly 30 per cent may be contained in the skin under the influence of certain conditions and applications. Ordinarily, there is one-fourth of the blood in the heart, lungs, and great blood-vessels; one-fourth in the liver; one-fourth in the skeletal muscles; and one-fourth in other organs. The circulation of the CIRCULATING FLUIDS 53 skeletal muscles is influenced with that of the skin, and usually the same changes occur simultaneously in both. The amount of lymph in the body is variously estimated from one-fourth or one-fifth to one-third of the entire body weight.10 This enormous quantity of fluid is affected in the same way by physiologic applications as the blood. Kowalski,11 in 1901, reported a series of experiments under- taken to determine the effects of thermic irritants upon the movement of lymph and upon the vasomotor nerves of the lymph vessels. Briefly stated, his conclusions are as follows: — Thermic irritants control the flow of lymph, not only indi- rectly, but also by altering the calibre of the lymph vessels. These changes are the same as those in the blood-vessels, i. e., low temperatures contract them, while high temperatures dilate them. These effects are produced through the nervous system by way of the vasomotor nerves. The vasomotor nerves of the lymphatic vessels act independently of those controlling the blood-vessels and general circulation. It will be seen from this that the use of the alternate hot and cold leg bath for oedema is based upon demonstrated physiologic facts, the lymphatics as well as the blood-vessels taking part in the absorption of tissue fluids. Experiments on the production of lymph in the limbs have also brought out in a very striking manner the rationale of massage in dropsy. In the resting limb there is no flow at all from the tissue spaces. Berlin blue injected under the skin finds its way into the lymphatics with extreme slowness, unless absorption is facilitated by kneading the limb or by carrying out passive movements. " Ludwig has shown that the lym- phatics of the aponeuroses. are so arranged that every move- ment, active or passive, tends to pump fluid from the tissue spaces into the lymphatics, and from the smaller into the larger lymph trunks. Experiments on the production of lymph in the limbs have, therefore, always to be associated with kneading or passive movements in order to get any lymph flow at all." 10 Fourier, Cuneo, and Delamere — The Lymphatics, p. 7. 11 Blatter fur klinische Hydrotherapie, January and February. 1901. 12 Starling— Fluids of the Body, p. 72. CHAPTER V ANATOMY AND PHYSIOLOGY OF THE SKIN (Continued) THE SUDORIPAROUS OR COIL GLANDS THE sweat glands are distributed throughout the entire skin. They are most numerous in the axilla, palms, and soles, where they are also of unusual size. And, according to Krause, there are between 2000 and 3000 per square inch. The total number in the body is estimated at from 2,000,000 to 3,000,000, and their aggregate length uncoiled and placed end to end, as about eight miles; while the total surface of the ducts is estim- ated at 11,000 square feet. These figures serve to show the great importance of hygiene directed toward the maintaining of their normal functions and the tremendous effect of bad hygiene in causing disease. The sweat gland consists of a long tubule, coiled at the deeper end. The globular coil (glomerulus) lies in the sub- cutaneous fat, or in the fat columns of the deeper part of the corium. Next to the epithelium in the coiled part of the tubule, are found smooth muscle fibers, disposed longitudinally, or spirally. These muscle fibers are doubtless concerned, along with the erectores pilorum, in the checking of perspiration which results from cold applications. Each tube is about four or five millimeters long. Three-fourths of this makes up the coil.1 The sweat pore — that part of the duct lying in the epi- dermis— is a wall-less channel, spiral or straight in course. The outer end is funnel-shaped. The pore is in free communi- cation with the juice spaces of the epithelium, as was mentioned in considering the lymphatics of the skin. It will be seen from 1 Bohm. Davidoff, and Huber— Histology p 397 (54) THE COIL GLANDS 55 this fact that the drying of the skin is not alone a drying of the surface, but also a drying of the fluid found between the deeper cells of the epidermis. A capillary network of blood-vessels surrounds the coiled part of the gland. Nerves from the sym- pathetic neurons end in the secreting cells. Figs. 13 and 14. Diagrams showing similarity in structure of the tubules and glomeruli of the kidney to the coil glands of the skin and their vascular network. As the uriniferous tubules are many times the length of the coil glands, no comparison of the size is in- dicated by the drawings. Fig. 13. U. T. — uriniferous tubule, C. B. — capsule of Bowman, G. — glomerulus. Fig. 14. Sudoriparous gland: E.-j«pithelium of skin, P. D.— perspiratory duct, C. G. — coiled portion of gland, V. N. — vascular network. The secretion of the sweat glands varies with the character and amount of food and drink, the state of health, temperature and humidity of the air, etc. About 98 per cent is water,2 the remainder being chiefly salines, pigment, and a small amount of fat. In twenty -four hours, one and one-half or two pints of water are excreted. This is approximately double the amount 2 Hyde and Montgomery — Diseases of the Skin, p. 46. 56 ANATOMY AND PHYSIOLOGY OF THE SKIN exhaled by the lungs. Contrary to the general notion, the skin does not excrete large quantities of deleterious substances. In health the poisons excreted by the skin are very small in amount. Vicarious Functions of the Skin. There is a great similarity in the structure of the tubules and glomeruli of the kidney to the coil glands of the skin and their vascular tufts (Figs. 13 and 14.). This very similarity in structure suggests a similarity in function. The perspiration and urine are both excretions and, to a great extent, may replace each other. In disease this fact becomes very evident. When the kidneys become incompetent to excrete certain wastes, these are often found in the sweat and, vice versa, when perspiration is interfered with, more work is thrown on the kidneys. In warm weather excessive perspiration occurs, while the urine is scanty. In cold weather the perspiration decreases and the urine increases in amount. Urea, normal in the urine to the extent, of about 2 per cent, is found in normal perspiration to the extent of 0.1 to 0.2 per cent. Schottein, in certain cases of the uremia of cholera, saw the whole body covered with a thin white crystalline layer of urea.3 In cases of pyemia, where the staphylococcus albus was present in the blood, the sweat induced by packs has shown abundance of the staphylococcus. The same is true of many other diseases in which there are germs in the blood (bacteri- emia), the kidneys also excreting the germs. Bouchard4 has called particular attention to the cutaneous eruptions which accompany auto-intoxication, especially with a dilated stomach, or after eating mussels, shell-fish, etc., as being due to pto- maines eliminated through the skin. In some forms of auto- intoxication various poisons excreted by the skin may be appre- ciated by their odors. The peculiar odors about prisons and asylums are doubtless more or less due to the volatile poisons of faulty nutrition which the skin exhales. In cases of jaundice bile pigments are found in the sweat so that sheets and bedding are stained by it. Sugar may be found in the sweat of dia- betics and in the sweat of cases of forced glycosuria. Dr. Herbert U. Williams of Buffalo has shown5 that in 3 Baruch— Principles and Practice of Hydrotherapy, p. 26. 4 Auto-Intoxication in Disease, pp. 20, 162. 5 Journal of American Medical Association, April 17, 1909, p. 1276. PERSPIRATORY INFUENCES 57 chronic nephritis the sweat glands are extensively altered in structure. He examined skin from various parts in seventy cases of chronic nephritis and found a variety of conditions including desquamation of the epithelium, cystic dilatation of the tubules, atrophy of the tubules, and cast-like material in the tubules. In fourteen cases arteriosclerosis of the arteries of the skin was present. In some cases hypertrophy of the epithelium was observed, even to the formation of two or three layers of cells. Dr. Williams states that these studies were undertaken because, from the earliest ages, faith has been placed in the efficacy of active skin excretion in cases of nephritis. SUMMARY OF PERSPIRATORY INFUENCES Factors which govern perspiration: — 1. Degree of internal or external heat. 2. Amount of water in the body. 3. Amount of blood in the skin. 4. Specific stimulation of secretory (sweat) nerves, as by electricity, shock (as cold sweat of fright, etc.), and drugs. Conditions that give rise to increase of perspiration: — 1. Applications of heat, as hot air, hot water, steam, light. 2. Water drinking, especially of hot water. 3. Exercise. 4. Mechanical irritation, as friction or percussion. 5. Diaphoretic drugs. Conditions that decrease perspiration: — 1. Chilling or cold applications. 2. Excretion of large amounts of water by the kidneys or bowels. 3. Certain drugs, as atropine. 4. Local applications of astringents, or cooling preparations, as alcohol, vinegar, talcum powder, etc. The facts listed in the above outline are perhaps too evident as matters of every-day experience to need comment. In prac- tice we usually combine two or more of these measures in order to secure quicker and better results. For example, the drink- ing of cold water before and during the electric light bath 58 ANATOMY AND PHYSIOLOGY OF THE SKIN greatly enhances its results. The drinking- of hot lemonade in conjunction with hot packs, vapor or Russian baths, likewise gives quicker results. Heat applied to the skin, not only in- creases the blood about the coil glands, but also stimulates, directly, the secreting- cells. Cold, applied to the skin, causes a decrease in the amount of the blood in the skin and so lessens the available fluid which the sweat glands utilize for secretion. It has been shown that drugs having a specific action upon the sweat glands, cause alterations in the structure of the secret- ing cells, thus proving detrimental to their healthy activity. THE SEBACEOUS GLANDS The sebaceous glands are sacciform in shape, found in con- nection with the hairs of the skin and pouring their secretion into the follicles of the hair and lanugo. The oil or sebum is produced by fatty degeneration of the gland cells themselves; more cells being produced next the basement membrane to take their place. It is designed to oil the hair and skin. The glands are situated next the hair follicle, between it and the piliary muscle. Heat softens the oil in the glands, and thereby brings about its extrusion. Oil is a non-conductor of heat. Covering the skin with oil hinders both the elimination of heat where the surrounding atmosphere is cold, and the absorption of heat where the atmosphere is heated. ABSORPTION BY THE SKIN We are not greatly concerned in hydrotherapy with the ab- sorptive powers of the skin. Oily substances are most readily absorbed, watery solutions not at all. Absorption of oily sub- stances, alcoholic or ethereal solutions is greater after a warm bath and cleansing of the skin, since the sweat pores are then open and the increased circulation favors absorption. Guy Hinsdale 6 gives an excellent summary of the subject of cutaneous absorption from which we quote the following: — "James Currie, who wrote one of the first and best books on hydrotherapy, states that there is no increase of weight in the bath, and while the skin remains sound and entire no absorp- tion of solid, liquid, or aeriform elastic fluid takes place on the 6 Hydrotherapy. p. 21. CUTANEOUS RESPIRATION 59 surface. In the instances that are supposed to favor the con- trary opinion, it will be found that the article is forced through the epidermis by mechanical pressure, or that the epidermis has been previously destroyed by injury or disease." Rohrig in experimenting- with a bath to which potassium iodide had been added, found that full immersion in this for three-quarters of an hour gave rise to no iodine in the urine. Negative results have also been obtained by a number of other observers using various soluble substances. Substances caus- ing injury to the skin may be absorbed, also ethereal solutions of certain alkaloids, but R. Winternitz found no evidence of the entrance of these substances from watery solutions. One must, therefore, conclude that the mineral constituents of water — other than strong salines and gaseous constituents — have no effect whatever upon the human system when applied to the unbroken skin. Hinsdale makes a very apt statement of the case, "We are thus forced to the conclusion previously enunciated, — that the mineral waters, the analysis of which are quoted with such particular exactitude unto the third or fourth decimal place of grains per gallon, are neither more or less effi- cacious on that account." CUTANEOUS RESPIRATION To a limited extent, the skin acts as a respiratory organ when the temperature is above 85° F. About 0.5 per cent of the total gaseous exchange of the body occurs in this manner. The amount of CO2 exhaled at 91.4° F. may be doubled at 93° F., increasing in about the same ratio as the watery excretion. Hot moist applications to the skin increase the elimination of COz, since diffusion of gases is hastened by the moistening of the surface and the larger amount of blood brought to the skin. It is said that, in diseases of the heart and lungs, where there is diminished excretion of COz in the expired air, cutaneous ex- halation is increased. In asthmatic dyspnoea when the skin becomes flushed and perspiration free, the dyspnoea is somewhat relieved. General perspiration produced by hot applications also relieves dyspnoea. In either case, however, the result is probably due more to the increased rate of the circulation of 60 ANATOMY AND PHYSIOLOGY OF THE SKIN blood through the lung's reflexly produced by the application, thus increasing- the amount of oxygen there absorbed, than to increase of cutaneous respiration. THE SKIN A HEAT REGULATOR This will be considered again under the subject of heat regu- lation. The skin itself takes part in heat loss only, although through nerve connection, it is one of the most important means in controlling heat production. ' The loss of heat by the skin amounts to about 77 per cent of the total heat loss. ' ' 7 It is, there- fore, the most important factor in the elimination of heat. The regulation of heat loss by the skin is accomplished by variations in the amount of heat radiation and evaporation of sweat. It will be seen that heat applied to the skin increases heat loss in two ways: first, by dilating the surface vessels and quick- ening cutaneous circulation, thus increasing heat radiation and convection; second, by inducing free perspiration and the con- sequent loss of heat by evaporation. Conversely, cold applied to the skin decreases heat loss by driving the blood inward and checking perspiration. It is chiefly through the temperature nerves of the skin that this organ influences heat production. So profound is this influence that extensive burns, covering more than two-thirds of the body, are fatal through destruction of the sensory nerve terminals. Not only is heat elimination interfered with, but metabolism becomes excessive and heat production is immensely increased. Internal congestion and inflammations result, with a fatal termination. After a drunken debauch the unfortunate victim is in great danger from exposure to cold, because the sensibility of the nerves is temporarily destroyed, so that the heat-regulating centers are not apprised of the danger. The boy who died from gilding of the skin to represent an angel is an example of the disturbance of the heat mechanism due to interference with the regulatory functions of the skin. After varnishing of the skin the temperature at first rises and then falls accompanied by symptoms of poisoning due to defective oxidation. 7 Starling— Human Physiology, p. 505. CUTANEOUS NERVES 61 NERVES OF THE SKIN We have already considered the secretory and vasomotor nerves of the skin. The third set of cutaneous nerves of impor- tance in hydrotherapy are those already mentioned as forming the connection by which the skin regulates heat production and loss, viz., temperature nerves. These nerves are not uniformly distributed in the skin. They are more numerous in certain localities than in others, and where more numerous, the tem- perature sense is more acute, such as the tips of the fingers, the cheeks, and backs of the hands. These are the parts we instinctively use to test the safety of hot-water bottles and other hot applications. The recognition of heat is confined to the ' ' hot spots ' ' and that of cold to the " cold spots," as can readily be proven by experiment. Lightly resting the point of the pencil on the skin will produce a sensation of heat or cold according as it rests on a hot or cold spot. The two sensations are appreciated by dif- ferent end organs and travel by different fibers. Applications to . certain localities produce more intense tem- perature sensations than to others. Applications to a large area produce a greater intensity of sensation than applications to a smaller area. These facts are utilized in controlling the circu- lation reflexly and mechanically (q. v.) . The temperature sense is more acute when the skin is warm or after warm applica- tions. This fact is utilized to prepare the body for cold appli- cations, so that the reaction will be greater and appear more promptly. As has been mentioned, the temperature of the skin is the zero of the temperature sense. The skin contains also the end organs of tactile sensation. They are more numerous in certain localities than in others, as are the temperature nerves, and likewise serve to make the con- nection by which cutaneous applications influence internal parts. CHAPTER VI THE CIRCULATION-REFLEX EFFECTS DURING health, there are vasomotor influences constantly playing1 upon the arteries in all parts of the body. These influences hold the vessels in "tone," i. e., control the rhythmic oscillations in calibre, so that blood pressure is maintained. These influences seem to emanate from a vasomotor center which is located in the medulla oblongata in the floor of the fourth ventricle. " Irritation of this center causes contraction of all the arteries and, in consequence, increase in arterial blood pressure." "Paralysis of the center causes relaxation and dilatation of all the arteries, with enormous reduction in blood pressure. Under normal conditions the vasomotor center is in a state of moderate tonic excitation." While this center exercises a controlling influence over all, it is not the only vasomotor center. "Centers for the vascular nerves, both vasomotor and vasodilator, are distributed throughout the entire spinal axis." (Plate 77.) " They can be excited reflexly, although they are subordinated to the dominating centers in the medulla oblongata." 2 "It is obvious that such a mechan- ism as that described ... is susceptible of reflex stimulation through sensory nerves, and according- to our g-eneral knowl- edge we should suppose that a tonic center of this kind may have its tonicity increased (excitation) or decreased (inhibi- tion)." It is to the reflex stimulation of these centers that we now wish to turn our attention, for through this channel, hydrotherapy produces some of its most important effects. 1 Landois— Physiology, 1905. p. 762. 2 Landois— Physiology, p. 735; see also Howell— Physiology, p. 564; and Foster— Physi- ology. 1898. p. 285. 3 Howell— Physiology, p. 560. (62) PLATE II. Visceral sympathetic nerves. Diagram showing the areas of exit from the spine of the sympathetic nerves controlling the various organs of the body. The red lines in the table indicate vasomotor areas. Stimulation of the centers from which these sympathetic nerves originate affect the organs supplied by them. (Pil- grim.) EXPERIMENTS IN REFLEX EFFECTS 63 Maximilian Schiiller,4 in experimenting- on trephined rabbits, observed that severing- single nerve trunks on one side of the animal produced a distinct (though transient) dilatation of the pial vessels on the corresponding .side, thus proving" that the blood-vessels of the piamater are held in steady tone by con- tinuous excitation from the cutaneous sensory nerves. This result was observed only on the side of the severed nerve so that it could not have been due to shock or pain. Naumann has demonstrated clearly that the effects of ex- ternal irritants upon the circulation within the body are really reflex. He separated the head of a frog from the body, leaving- them connected by the medulla oblongata only. He next severed one leg", after preventing- loss of blood by tying- the vessels, so as to leave it connected with the body by the sciatic nerve. Now he applied thermal, chemical, and electric stimuli to the foot of the partially severed leg-, while he observed, under the microscope, the mesentery of the frog. Shortly after g-entle irritation of the peripheral ending's of the sciatic nerve in the foot, the circulation in the vascular net- work of the lung's and mesentery was accelerated, and resumed the former condition slowly after the withdrawal of the irritant. A more severe irritation produced retardation of the flow, and even stasis occurred, as if the heart had become temporarily paralyzed. A strong irritant produced dilatation; a feeble one, constriction of the vessels. The effect of these peripheral irri- tations on the heart was also noted. A strong- irritation of the skin weakened its circulation; a feeble irritant strengthened it. As there was no possible vascular or nerve channel from the part irritated to the part thus visibly affected, the conclusion is inevitable that the effect is entirely reflex. Hot water acted precisely as other irritants." These experiments also prove that there are two reflex means by which the circulation may be influenced, viz., reflex stimulation of the vasomotors, pro- ducing changes in vascular calibre, and reflex stimulation of the heart muscle itself. Another point, brought out by the experi- ments of Rohrig, is that when intense cutaneous irritants pro- 4 Deutches Archiv fflr klinische Medicin, No. 4, 1874. 5 Baruch— Principles and Practice of Hydrotherapy, p. 37. 64 REFLEX EFFECTS duce considerable slowing- of the heart beat, they also increase its force. This is the effect of a prolonged cold application, whether general, as with the Brand bath, or local, as with the ice bag to the precordia. REFLEX AREAS The fact of reflex stimulation being; established, we may next consider the location (topography) of the various reflex areas. While the brain, heart, and other viscera may be reflexly influenced by stimuli applied to many different cutaneous areas, some even very remote from these organs, the maximum effects are produced by stimulation of certain very definite and well recognized areas. In general, it may be said that the skin over an organ is reflexly related with that organ. In most cases, it is not difficult to trace the nerve connection. " In general, the skin overlying an organ is reflexly associ- ated with it, which is the reason why applications of electricity over an organ usually influence it, and not altogether because the current is passed through the organ. When these areas are studied comparatively, it is noted that they are practically the same as those regions pointed out as showing reflex pain, which would suggest a nervous path from the organ to the skin and from the skin to the organ, the terminations of which are in the same visceral and cutaneous fields." 6 So definite and cir- cumscribed are some of these areas that B. G. A. Moynihan has frequently observed, in cases of duodenal ulcer, a small hyper- sensitive spot in the skin covering the abdomen, directly over the ulcerated area. It is no larger than a six-pence and he attaches much value to this phenomenon in differentiating ulcer.7 It must not, however, be supposed that the reflex path from the viscera to the skin over which pain is referred is the same path as that utilized in therapeutics for reflex effects upon the internal organs. Nor are the skin areas to which pain is referred always the same areas that should be utilized to 6 S. D. Ludlum— The Relationship between the Spinal Cord, the Sympathetic System and Therapeutic Measures— Journal of American Medical Association, May 2, 1908 pp 1401—1405. 7 W. D. Haines— The Differential Diagnosis of Duodenal Ulcer and Gall Stones- Surgery, Gynecology. and Obstetrics, March, 1908, p. 279. THE REFLEX ARC 65 influence reflexly the organ in which the cause of pain is located. For example, in the case of liver and gall-bladder disease, there is frequently a pain in the region of- the right shoulder or shoulder blade, but it is not to this region that applications are made to relieve distress due to hepatic or biliary affections. The various cutaneous areas to which the pain or tenderness, due to visceral disease, is referred, are spoken of as the derma- tomes of Head. They are in some cases of considerable service in diagnosis and are sometimes serviceable as a guide in the placing of therapeutic applications. They can not, however, be implicitly relied upon for either purpose. Relative to this unreliability Abrams 8 says, ' ' The elicitation of the dermatomes of Head is a tedious method of examination and not always accompanied by satisfactory results for the reason that a great amount of experience is necessary. Alsberg in the examination of two hundred women (with gynecological affec- tions) found cutaneous areas of hyperalgesia in only seventeen, ten of whom were hysterical. Therefore, he could attribute no diagnostic import to the zones in question beyond commenting on the fact that hysterical stigmata must be excluded before the zones of hyperalgesia could be regarded as trustworthy." Diagnosis and therapeutics based on para-spinal tenderness must, therefore, be of a highly imaginative character and espec- ially so when approached from the standpoint of a prejudgment as to the causes of disease and consequently its treatment. The law that the skin over an organ is reflexly related with that organ may be regarded as an amplification of Hilton's law: The principal nerve to a joint not only supplies the articular sur- faces but also some of the main muscles that move that joint and the skin over these muscles.9 In the case of the viscera, however, the deeper part of the reflex arc consists of a sympathetic neuron. THE REFLEX ARC The reflex arc consists of several parts (Frontisplate and Fig. 15.}. In general, the following is the path taken by a stimulus arising in the skin from a thermic application and traced as a 8 Spondylotherapy, p. 71. 9 Treves— Applied Anatomy, 1901, p. 209. 5 66 REFLEX EFFECTS V.f: reflex stimulus to the organ underlying the skin surface treated. From the skin it is conveyed by a sensory (temperature) nerve along a nerve trunk to the posterior root of the spinal nerve; entering the posterior root ganglion, where the fiber is seen to be the distal axon of a T-cell, it passes on through the cen- tral axon of the T-cell into the posterior side of the spinal cord. On entering the cord, the fiber immediately divides into an as- cending and descending branch , both located in the posterior white columns and which give off collaterals to the gray mat- ter.10 The ones we are con- cerned with end in tufts about the cells of the column of Clark. According to Starling, " the vasomotor center in the me- dulla corresponds in position to the column of Clark which is doubtless that which represents the vasomotor center through- out the rest of the cord. From these cells, axons pass either into Gower's tract and end in the cerebellum,12 or pass out with the anterior root, and through the white ramus to the ganglion of the lateral sympathetic chain. 1S Passing directly through this or up or down through an adjacent ganglion, they end in a peripheral ganglion from which the viscus is supplied. The fibers of the white ramus which pass through the gang- lion and go to the periphery are known as the splanchnic efferent 10 Whitaker— Anatomy of the Brain and Spinal Cord, p. 38. 11 Physiology, p. 259. 12 Ludlum -Journal of American Medical Association, May 2, 1908, p. 1403. 13 Whitaker— Ibid, p. 39. Fig. 15. Diagram to show path of vasoconstrictor fibers from vasoconstric- tor center to the blood-vessels and the path for reflex stimulation, v. c. — the vasoconstrictor center, 1. — the central neuron of the vasoconstrictor path, 2.— the spinal neuron (preganglionic) , 3. — the sympathetic neuron (ganglionic) , a.— the arteriole. 4.— the sensory fibers of the posterior root connecting by collater- als with the vasoconstrictor center and subcenters, 5.— fiber from cortical cell acting upon the vasoconstrictor center. (Howell.) REFLEX PATH TO HEART - 67 fibers, and constitute the secretory fibers of the splanchnic glands and the motor fibers of the muscular tissue of the splanchnic blood-vessels and viscera."" By studying carefully the above reflex path, it will be noted that a stimulus may affect (be shunted to) cells either above or below {Fig. 15.} the level at which it enters the spinal cord. And again, the fiber that conveys the reflex stimulus to the viscera may pass up or down in the gangliated cord. This fact is of importance in explaining why cutaneous nerves are con- nected reflexly with splanchnic nerve trunks not arising in the same segment of the cord.15 Of the many reflex paths, we may pick out two as serving to quite fully illustrate reflex effects. First, let us study the reflex arc concerned in the effect produced by an ice bag applied to the precordial region. And second, the arc concerned in the reflex between the skin of the epigastrium and the stomach. The Heart. Before considering the reflex arc, we should understand that the heart is supplied with nerves from two sources. {Plate III.} First, through the vagus nerve (fibers of accessory part of the spinal accessory nerve) with inhibitory fibers, / — O ~V° Hi •- C — i F - s| il iill • c c.2 .§2 P (90) CIRCULATING FLUID 91 so raise blood pressure. After a brief rise, hot applications to the precordia decrease blood pressure. Short cold applications to the precordia increase the heart rate, while long- cold appli- cations decrease ••••••••••1 the heart rate. In the normal person both results are associated with a rise in blood press- ure. Rapidly alter- nating hot and cold applications to the precordia have much the same ef- fect as short cold applications, ex- cept that the stimu- lation , being- great- er, causes a great- er rise in blood pressure. This rise is less perma- nent than that ac- companying' pro- longed cold appli- cations to the pre- cordia. These points have been thoroughly dis- cussed elsewhere. 2. The Amount of the Circulating Fluid. An increase in the quantity of blood in the vascular system, other thing's being- equal, increases blood pressure. In order to intelligently apply those therapeutic measures which are designed to maintain blood pressure through changes in the amount of the circulat - Fig. 24. Cardiometer tracing from a dog's heart showing effect of increasing the volume of circulat- ing fluid on the total output and volume of the heart. Between the parts A and B 30 c. c. of warm physiologic salt solution were injected intraven- ously, and between B and C 20 c. c. more. Both the systolic and diastolic volume are increased, i. e., the heart is more distended during diastole, and does not contract to its normal size in systole. The re- sult is a very largely increased output. (Roy.) ;,j BLOOD PRESSURE ing fluids, it is necessary to obtain an understanding of the laws governing the intake and output of body fluids and also the absorption of extra- vascular tissue fluids. Modern knowl- edge of the fluids of the body has been summarized by E. H. Starling:.1 From this source we have drawn much of the fol- lowing: information. The absorptive membranes of the body possess a discriminat- ing: or irreciprocal permeability to fluids, /. e., fluids containing certain saline substances are readily and rapidly absorbed, while fluids containing- other salts are either not absorbed, or only after long contact. " If the solutions contain sulphates or tartrates, i, • ££ *~~ ••— -• V »-^ ^ ^ r^ Water Bath at 36.25°C. • on 120 110 inn A. _A^ Hi V ' v * -^ •**«- ****• ^ en / '^ ^ H ~-J T Water Bath at 28.75° C. PLATE IV. Chart showing influence of baths of different tem- peratures on blood pressure and pulse rate in a healthy man of twenty-six; red lines— blood pressure, black lines — pulse rate. (Riva-Rocci's sphygmj (Muller.) BLOOD PRESSURE EFFECTS 99 capillary arterial tension, as taken by Gartner's tonometer (Fig. 27.} from 13.5 cm. to 14.5 cm. The first observation was made immediately before, and the second immediately after the drinking- of the cold water. In another clinical experi- ment '° an initial arterial tension of 9 cm. was, by an electric light bath, raised to 10 cm. within one minute. At the end of five minutes the tension had fallen to 8 cm. and in twenty min- utes to 7 cm. In another case 16 fifteen minutes in a full bath at 102° F. reduced the blood tension from 9 cm. to 6 cm. as shown by Gartner's tonometer. Hot air baths decrease blood pressure as shown in a series of observations by Tuttle 17 the average decrease in twenty cases was 12 mm. of mercury. Cold douches following this, quickly raised the blood pressure to normal, slightly below or slightly above. Carbonated baths have a tendency to raise blood pressure, although J. M. Swan18 has shown that this effect is not con- stant. The marked results of the artificial Nauheim bath are probably due more to the stimulation of vascular activity, i. e., of the peripheral heart than to vasoconstriction. The same may be said of the oxygen bath, though the majority of observers agree that its most usual result is a lowering of blood pressure. The breathing of cold air raises the blood pressure. B. R. Hoobler 19 observed a gradual increase of the low pressure in children suffering from tuberculosis, when these children were transferred to the open air. The raised pressure became more and more permanent as the out-door treatment was continued. These matters are discussed further in the part on therapeutics in connection with the treatment of various diseases. 15 Kellogg— Rational Hydrotherapy, p. 1122. 16 Ibid. p. 1128. 17 American Journal of Insanity, October, 1904. 18 Archives of Internal Medicine, August 15, 1912, p. 73. 19 American Journal of Diseases of Children, November 20, 1912. CHAPTER X THE CIRCULATION-CHANGES IN THE COMPOSITION OF THE BLOOD CORPUSCULAR ELEMENTS SUCH a large volume of experimental work has been re- ported along this line that we can not do more than tabu- late the principal results observed. The investigations of Professor Winternitz, and those of Strasser, undertaken at his request and reported in 1893, are considered the basis of our knowledge of these changes. The results obtained by all observers are so uniform as to leave no doubt of their reliability. After all sorts of cold procedures, involving the general skin surface and associated with mechanical procedures, after hot baths or douches when followed by cold applications, the blood counts reveal an increase in both the red cells and white cells, and a marked change in their ratio. In Winternitz' experi- ments the greatest increase in red cells amounted to 1,860,000 per cubic millimeter; in white cells, from 200 to 300 per cent; and in hemoglobin, 14 percent. On the first and third bath days of Strasser' s experiments, referred to in Chapter XI, blood counts were taken after the cold douche and after the graduated half bath. The counts were as follows: — Effects of Cold Douche Before After Red cells 4,570,000 5,200,000 White cells 4,600 6,400 Hemoglobin (Fleischn 85% 95% (100) BLOOD COUNT Effects of Graduated Half Bath Before Red cells 4,880,000 White cells 5,400 Hemoglobin - 85% The results in detail of some of the experiments performed by Winternitz are given in the accompanying- chart (.Fig. 28.} and table.1 After 5,420,000 8,400 95% Reds. $5% 20OOO 815% 24000 82£% 22000 77.5% ZOOOO 100% IBOOO 65.0% 11000 57.5% ISOOO 52.5%I3000 QS.9% 11000 tO.0% 9000 35.0% 7000 17.5% 5000 22.52 4000 11.5% ZOOO I.OOOQOO sooooo Fig. 28. Chart showing the effects of hydriatic procedures on the blood count and hemoglobin. Upright blocks with diagonal lines- red count, blocks with horizontal cross lines — white count, blocks in black— hemoglobin per cent. (Winternitz.) Cold Full Bath Before Immediately after After plus 1-2-hr, rest in bed Cold Rain Bath Before After plus 1-2-hr, exercise Scotch Douche Before After plus 1-hr, exercise Red Cells White Cells Hgb 5,380,000 5,222,000 5,422,000 4,820,000 5,510,000 4,460,000 5,000,000 8,400 16,700 21,640 4,500 10,600 7,400 11,600 70% 87% 95% 74% 77% 1 B. Buxbaum — Lehrbuch der Hydrotherapie, II Auflage, p. 35. 102 BLOOD COMPOSITION These changes were maintained for from one-half hour or one hour up to two hours or longer after applications, gradually returning to normal. The increase in the white cells was maintained longer than the increase in reds. These observa- tions have been confirmed by Thayer, Baruch, and Kellogg, in this country. Where do these cells come from? Repeated cold applications stimulate hematogenesis, as they stimulate all other functions, as is shown by the fact that in cases of anemia this increase in cells continues longer and longer after each succeeding appli- cation until finally a normal count is reached and maintained. But, of course, so great an increase as 30 or 35 per cent in the total number of reds and 200 per cent in the total number of whites could not result from a single application. This increase in the corpuscular elements in the peripheral circulation must be at the expense of the number elsewhere. Winternitz claims that this increase of cells in the peripheral circulation is due to the driving of large numbers of cells from the viscera, where stasis has taken place. Breitenstein 2 has confirmed this view by experiments upon rabbits. These animals were overheated in a hot box, before and after which the red cells in the peripheral circulation (ear) and viscera (liver) were estimated. Before the heating process, the cells in the ear and liver were equal in number. After it, there was an enormous increase in the red blood cells in the liver. Tschlenoff observed a decrease of 50 per cent in the white cells in rabbits subjected to a temper- ature of 42° C. for five or six hours. These experiments also confirm the observation of Winternitz and others, that general hot applications, much prolonged, decrease the blood count and the hemoglobin per cent, the white cells suffering a greater diminution than the reds. Not the least interesting of the observations made by Winter- nitz is that relating to the local increase in the blood count taken from circumscribed areas treated by cold or hot and cold douches, partial baths, etc., while counts taken from a distant part showed a decrease in both the red and white cells. Pro- longed local applications of heat not followed by cold, while 2 Archiv. fflr Exper. Path, und Pharm.. Bd. 32, 1896. MECHANISM OF DISTRIBUTION 103 resulting- in a local decrease of red cells and hemoglobin, in most cases produced an increase in the leucocytes in the same part.3 This experiment furnishes a rational basis for the local use of thermic applications to an infected part. Massage as well as hydrotherapy produces an increase in the number of the blood corpuscles, as shown by counts taken before and after treatment. The effect is at first temporary, but lasts longer and longer as the massage is continued from day to day or week to week until finally the improvement becomes perma- nent. Astonishingly good results have been reported by Mitchell 4 in cases of anemia. Mechanism of Distribution. The change in the distribution of the red and white cells produced by cold applications is to a great degree due to the stimulation of the peripheral circulation. This is not, however, the only factor in bring- ing about an increase of cells in the surface circulation. The viscera and their blood-vessels are subject to the reflex stimulation produced by cold applications. The contraction of the viscera and the visceral blood-vessels, caused by cold applications, drives their contained corpuscles to other parts, and these are taken up by the increased activity of the peri- pheral circulation and so redistributed. In both the liver and spleen the blood cells are especially prone to accumulation and stasis. The blood-vessels of both may be rendered very active; but owing to the additional muscle fibers in the capsule and trabeculae of the spleen, this organ exerts a greater effect upon the blood current than any other viscus except the heart. ' The most definite facts known about the spleen are in con- nection with its movements. It has been shown that there is a slow expansion and contraction of the organ synchronous with the digestion periods. After a meal the spleen begins to in- crease in size, reaching a maximum at about the fifth hour, and then slowly returns to its previous size. This movement, the meaning of which is not known, is probably due to a slow vasodilatation, together, perhaps, with a relaxation of the tonic contraction of the musculature of the trabeculae. In ad- dition to this slow movement, Roy has shown that there is a 3 Even in general hot applications a pronounced leucocytosis •was often observed. 4 Journal of American Medical Association, October 9, 1909, p. 1183. 104 BLOOD COMPOSITION rhythmical contraction and relaxation of the organ, occurring in cats and dogs at intervals of about one minute. ' ' Roy supposes that these contractions are effected through the intrinsic musculature of the organ, — that is, the plain muscle tissue present in the capsule and trabeculae, — and he believes that the contractions serve to keep up a circulation through the spleen and to make its vascular supply more or less independent of variations in general arterial pressure. The fact that there is a special local arrangement for maintaining its circulation, makes the spleen unique among the organs of the body, but no light is thrown upon the nature of the function fulfilled. The spleen is supplied richly with motor nerve fibers Doc 8 5 KILO ALL CONNCCTIONS WITH SPLE.EN SEVERED CXCE.PT ONE ARTERV * VEIN * 0 PRESSURE Fig. 29. Plethysmographic tracing of spleen (upper curve) from dog showing the spontaneous rhythmical contractions of this organ. (Schafer after Starling.) which, when stimulated either directly or reflexly. cause the organ to diminish in volume. According to Schafer these fibers are contained in the splanchnic nerves, which carry also inhibitory fibers whose stimulation causes a dilatation of the spleen." The blood of the splenic veins contains a much greater num- ber of white cells than the arterial blood supplied to the organ. Ifieacher* experimenting with Rhine salmon found four times as many leucocytes in the splenic blood as in the cardiac blood. This increase in the cellular elements increases the viscosity, 5 Howell— Physiology, 1909. p. 800. 6 Bunge— Physiologic and Pathologic Chemistry. Second English Edition, p. 229. VISCOSITY 105 and consequently tends to diminish the rate of blood flow. The gathering up of these cells, together with the closeness of the splenic meshwork in which the blood circulates, makes neces- sary some mechanism for additional propulsive force. "It is evident that the blood must meet with considerable resistance in passing through the close meshwork of the splenic pulp. To ensure a constant circulation through the gland, we find that the muscular tissue of the capsule and trabeculae has the property of rhythmic contraction. If the spleen be inclosed in a plethysmograph, or splenic oncometer, and its volume be recorded by connecting this with the oncograph, it will be seen that it is subject to a series of large, slow varia- tions, each contraction and expansion lasting about a minute, and recurring with great regularity (Fig. 29.). Superposed on these large waves are seen the smaller undulations due to the respiratory variations of the blood pressure, and on these again the little excursions corresponding to each heart beat. The contractile power of the spleen is under the control of the nervous system, and a rapid contraction may be induced by stimulation of the splanchnic nerves." 7 The use of cold applications, especially when accompanied by mechanical stimulation, such as the cold mitten friction to the abdomen and the cold splenic douche, have a decidely stimu- lant effect upon the movements of the spleen. The same is true of the revulsive compress and the alternate hot and cold douche to the splenic region and abdomen. Such stimulation increases the extent and force and greatly enhances the effi- ciency of the splenic contractions, thereby proving a powerful means of accomplishing the even distribution of the blood cells, especially the leucocytes. VISCOSITY Grawitz and also Burton-Opitz 8 have shown that cold appli- cations increase the viscosity and specific gravity of the blood, while warm applications decrease both. This thinning of the blood continued even after prolonged heating with free perspi- 7 Starling— Elements of Human Physiology. 1907, p. 514. 8 Journal of Experimental Medicine, January, 1906. ALKALINITY OF THE BLOOD c.c. 45 44 43 +2 41 40 39 38 37 36 35 34 33 32 SI 3fl Cold Procedure HolR-oced. FonJ)oocHe 50*10 Mm FuUBathKW, |O Pliil. £ >. !» 9 .2 o £ ^ 3rv *Sf» ^» 00 < flj < 9 5 ^ $ $ 71 / / / y / / / / / / / / / / / / i / / / / ' / \ / / / / ' / / / / / / / / / / / / / / / / / \ / / / / / / / / / / / / / / / / / / / [/ / / / $ / / / / / / / / / / / / / / / 7 / / / / / / / / / / / / / / / X / / / / / / / / / L/ / / / n ' ^ / / / / / / / / /i / / / ^ ? / / X / / /, / / / / / / / / / '. '. / / / / / / / / / ', / / / FIR. 30. Chart showing changes in the alkalinity of the blood under thermic procedures. Figures at left refer to alkalinity of 100 c. c. of blood serum in terms of c. c. of decinormalNaOH. (Strasserand Kuthy.) (106) ACIDITY OF THE URINE 0 2 6 8 10 12 14 16 \B Cold Ttacedure. Hot Proccduve. 56 52 50 48 46 42 40 38 36 34 32 30 28 24 22 20 IS 16 12 10 8 6 4 2 O Acid R?s lihal'e to- To lalfh 05*46:100 Total Fhos. =f C ):IOO AcidFhos.46^ Acid PhoA.^0%. 7 / ^/ / •/ ^ D«creasc •^Acidity Jncrea5e of Acidity in %. in. %. ^ ^ / ^ ••• 5 /, / 00 E. m ^ 1 I « ^ 0 1 5s ^™ / — J !n « * > 1 Tl 0 "1 • •^ / V ^ •• •S « a [-^ A* 5 / ^ 1 CQ a •^ '/ ' 0 £ r/ £ ^ > ' / r» ^ r S 01 "o « / / // / / ' ' , / ' , / /] ^ •^ j •» ^ / / ^ ^ £ o Si « 2; /, / 0 oooo ( in • ^ U ? k V o* "" ^ o\ ~ ^ * *- '/ ^> j: * - *=, S J c*- ^ tf- 8 « " « "« ~ /, UJ UJ W G a EU M a II 1^ 1? L > ,- 3 Fig. 31. Chart showing changes in the acidity of the urine un- der thermic procedures. Figures at the left refer to per cent of de- crease in acidity under cold treatment; figures at right, to per cent of increase in acidity under hot treatment. (Strasser and Kuthy.) (107) 108 BLOOD COMPOSITION ration. This result Burton-Opitz attributed to the blood be- coming relatively richer in serum at the expense of the tissues. These facts have been confirmed by Lowy and agree with the deductions of Winternitz and Knopf elmacher. In general, it may be said that conditions that produce vaso- constriction, increase the number of corpuscles in the vessels constricted, together with an increase in the specific gravity and viscosity of the blood. Conversely, conditions that relax the blood-vessels, decrease the corpuscular elements in the dilated vessels, together with a thinning of the blood. REACTION Strasser and Kuthy 9 performed experiments to determine the effect of hydriatic procedures upon the chemical reaction of the blood and urine. They found that procedures raising the body temperature, /. e., much prolonged heating measures, result in lessening the degree of alkalescence of the blood: also that cold stimulating procedures increase the alkalescence (Fig. 30.}. Strasser concludes that the result in the case of cold baths is due to an increase of oxidation over disintegration, i.e., to completer burning of acid organic substances, and hence to their disappearance. This is precisely what happens to the organic acids and acid organic salts of fruits and green vegetables. The organic radicle undergoing oxidation, largely into CC>2 and thO, leaves in the blood and body fluids the alkaline base of the salt and, therefore, raises the alkalinity of these fluids. While heating procedures increase oxidation, they bring about a greater disintegration of tissue, i. e., partial combustion and so result in an acidification, which acid products remain to be excreted as such in the urine. That Strasser 's deductions are correct is shown by the changes in the acidity of the urine accompanying these changes in the alkalinity of the blood. (Fig. 31.} In the case of cold procedures there occurs a decrease in the acidity of the urine parallel with the decrease in the acid of the blood (increase of alkalescence), thus proving that the acidifying substances have, to that extent, wholly disappeared. Conversely, in the heating 9 Deutsche Medizinal-Zeitung. June 15, 18%. quoted from B. Buxbaum— Lehrbuch der Hydrotherapie. II Auflage. pp. 38. 39. PRACTICAL APPLICATION 109 procedures an increase of acid in the blood (decrease of alkal- escence) is accompanied by a like increase in the acidity of the urine, showing- an actual increase in acidifying- substances unoxi- dized, and hence coming to excretion as such. PRACTICAL APPLICATION Some of the most beneficial results of hydriatic measures are due to the facts recorded above. In the majority of diseases, there is a reduction in the alkalinity of the blood. This is par- ticularly true of fevers and infectious diseases. An agent which will tend to restore the blood to its normal alkalinity will hasten all the processes of repair and raise vital resistance by supply- ing a more normal medium for the phagocytes. The role of the leucocyte (phagocytosis ) in combating infec- tion is now an established fact. The admirable researches of Metchnikoff along this line leave no doubt that the white cell itself is the prime factor (and that not excepting opsonin) in phagocytosis, the production and maintenance of immunity and the body's general resistance to bacterial invasion. He has shown 10 what signal disaster to the production, and even the continuance of immunity, results from the administration of alcohol, quinine, -opium, and other medicinal substances; this disaster being manifest by a diminution in the number and especially in the activity of the white blood cells. He further recommends the discarding of medicinal substances and the use of hygienic measures in the prophylaxis and treatment of infec- tious diseases. We have every reason to believe that cold hydriatic applications not only increase the number of leuco- cytes in the peripheral circulation, but also energize their action — amoeboid movements, phagocytosis, and the production of antibodies. This we might safely infer from the results obtained by cold applications in increasing muscular capacity, glandular activity, etc. All protoplasm, whether of muscle cells, glandular epithelium, or leucocyte, responds alike to the tonic influence of short vigorous cold applications. The writer has repeatedly seen infections of the hand and arm clear up in four to six days, or even less time, when treated by alternating 10 The New Hygiene. 110 BLOOD COMPOSITION extreme hot and cold immersion, while other cases not so treated have required a month to accomplish the same results. Since the blood and tissue cells are the source of opsonin, agglutinins, lysins, and other antibodies concerned in immunity, it is but reasonable to expect an increase in these as a result of the cellular stimulation produced by cold or alternate hot and cold applications. This has been partially demonstrated by Graziani,11 who found that of rabbits injected with the filtrates of typhoid cultures, and kept at different temperatures (plus 38, 37, 2, and minus 4° C.), those kept at low temperatures devel- oped more agglutinin than those kept at higfher temperatures. He also experimented with rabbits kept at 32° C., bathing- half of the number morning- and evening, in water at 20° C. for thirty minutes. The animals treated by bathing produced more agglutinin than the others. These facts demonstrate the truth of the Scripture statement that the blood is the life. The statement has not only its spirit- ual application, but is also founded upon demonstrated physical facts. "Notwithstanding the many antiseptics, germicides, etc., that have been vaunted for the treatment of infectious diseases, the ivhite blood cell itself is the most efficient germicide known, and will always retain its high place in the defence of the body against bac- terial invasion; furthermore, the agent which assists the body by augmenting its natural powers of defence will never occupy a place secondary to purely artificial and chemical means of destroying the invaders." 11 Centralblatt filr Bakteriologie, 1907. I, XLII, 633. 12 Abbott— Elements of Hydrotherapy for Nurses, p. 54. CHAPTER XI NITROGENOUS METABOLISM AND EXCRETION TISSUE changes lie at the foundation of all functional activ- ity. There can be no vital action without corresponding qualitative and quantitative changes in tissue composition. It must, therefore, follow that agents, such as thermic impressions, in awakening functional activity, should at the same time pro- duce profound alterations in absorption, metabolism and excre- tion. Without giving undue prominence to this phase of the subject, it would be impossible to discuss it here in anything like a complete manner. Those desiring to become more thoroughly conversant with the behavior of metabolism under hydriatic therapy should study the original reports of such re- search. Along the line of nitrogenous metabolism none are more instructive than those of Dr. Alois Strasser, assistant to Prof. W. Winternitz in the Allegemeine Poliklinik of Vienna, from whose monograph entitled, '"The Behavior of Metabol- ism under Hydriatic Therapy," l is drawn much of the data for the following discussion. Cellular activity is affected reflexly in the same way as other body functions. Tissue changes occur in all parts of the body, but those metabolic activities with which we are chiefly con- cerned may be traced to the muscles as the seat of the great majority of oxidative processes. The liver is also to a large extent concerned in metabolism, both nitrogenous and carbon- aceous. It is not necessary that the muscles be excited to 1 Das Verhalten des Stoffwechsels bei hydratischer Therapie— Fortschritte der Hydro- therapie, Festschrift zum Vierzigjahrigen Doctor jubilaum des Prof. Dr. W. Winternitz, herausgegeben von Dr. A. Strasser und Dr. B. Buxbaum, Wein, 1897. (Ill) 112 NITROGENOUS METABOLISM perceptible contraction in order to effect metabolic changes. Through the innervation of the muscles, oxidation is controlled and may be gfreatly increased by hot or cold applications, with- out visible contractions. This conclusion was arrived at by Rohrig and Zuntz who further confirmed their opinion by ex- periments upon animals "in which the innervation of the muscles was held in obeyance by arrow poison. In such ani- mals tissue change was not only not increased by cold, but was even reduced one-half." Other stimuli than cold also affect tissue changes. The relative value of various cutaneous stimuli, varying degrees of heat, and the quantitative response of meta- bolism is best studied with carbonaceous metabolism (g. v.). EFFECTS OF COLD Strasser conducted two series of experiments at different times. In \hefirst series two young men were selected as sub- jects. The daily ration, urine, and feces were carefully meas- ured, and from chemical analyses and estimations from these, the results were obtained. The procedures were such as would ordinarily be administered to patients. In the second series a single individual was chosen. In this series the intake con- tained 122 gm. of proteid (19.0 gm. nitrogen) besides carbohy- drate and fat. The output in feces and urine was measured for five days in order to establish the normal quantities of the various constituents for the individual under experiment. ' The bath period lasted three days. On each day the man received in the morning at 8 'o'clock a friction at 14° R. (63.5° F.). Forenoons at 11:30 a general cold ram bath with moving fan douche, and afternoons a half bath at 22° cooled to 18° R. (81.5° to 72.5° F.) of four minutes duration. Moderate exer- cise followed each procedure, as much as seemed necessary for warming, i. 2 elimination of 91 per cent. Observations made on an average nearly an hour after the bath, still revealed an increase of 22 per cent in the oxygen consumed and 16 per cent in CO2 exhaled. Rubner has shown that metabolism is at a minimum under temperatures from 91.4° to 95° F. (33° to 35° C.). A fall of every 1° C. in the surrounding temperature increases metabolism by 2 or 3 per cent. From the above observations we may deduce the law thaf applications below the skin temperature increase respiratory changes in proportion to the degree of cold. Neutral tempera- tures exert but little influence. Temperatures above that of the skin surface again increase the respiratory function in pro- portion to the degree of heat. Rubner4 found in his experiments that a douche produced more than double the change produced by a bath at the same temperature, each continued for the same length of time, viz., 3 1-2 to 5 minutes. The accompanying table shows the increase in per cent. 2 Archiv fur Hygriene, 1903. Bd. 46. 3 The normal respiratory quotient :en inhaled by the amount of carbon i 4 Archiv fflr Hygiene. 1903. Bd. 46. p. 390. 3 The normal respiratory quotient is 0.9 and is found by dividing the amount of oxy- gen inhaled by the amount of carbon dioxide exhaled. MECHANICAL STIMULI 129 Douche at 61° F. Bath at 61° F. Volume of air plus 54.5% - plus 22.9% CO2 exhaled "149.4 "64.8 O consumed 110.1 " 46.8 These observations prove the immense advantage of mechani- cal stimuli combined with thermic and also of exercise follow- ing: hydriatic treatment, especially when taken in the open air. A swimming bath or cold rubbing bath produces more decided tissue change than quiet immersion for the same reason. The same is true of massage following baths of whatever tempera- ture. At Aix-les-Bains a specialty is made of what is called the massage douche. This consists of deep-kneading of the muscles given while one or more streams of water are pouring over the parts treated. The Turkish shampoo following a Turkish or Russian bath also combines many of the procedures of massage, and is very popular with the obese. All such combinations of extreme thermic with vigorous mechanical stimulation are of great advantage in the treatment of obesity since the resultant oxidation of carbon compounds is more than double that produced by thermic stimulation alone. The lung gymnastics produced by hydriatic applications are by no means the least important factor in the results produced by hydro- therapy. CHAPTER XIII MUSCULAR CAPACITY restorative effect of warm baths in relieving- the sense 1 of fatigue, and the tonic effect of the cold douche or spray in overcoming the effects of fatigne, are familiar to all who are acquainted with the practical application of hydriatic proced- ures. These effects are extensively used by athletes in over- coming the exhaustion of severe or prolonged exertion. And medically considered, they are by no means the least impor- tant of the results obtained by hydriatic applications. In 1892 and 1893 Vinaj and Maggiori * reported a series of experiments undertaken to show the effect of hydriatic meas- ures upon the capacity of the muscles for work and their resist- ance to fatigue. These investigations were made with Mosso's ergograph {Fig. 36.). This instrument is so constructed as to hold the hand and forearm stationary in the body of the appa- ratus, while one finger is left free for flexion and extension. The forefinger, or middle finger, is usually employed so that, by means of a cord over a pulley, it raises and lowers a weight. This is kept up until the muscles are fatigued and unable to contract longer. A writing point makes a graphic record on the drum of an upright or horizontal kymograph. Their ex- periments were done with a weig-ht of three or four kilograms, raised every two seconds. In one experiment (Fig. 37 A.) the middle finger of the right hand was, under normal conditions, able to execute fifty con- tractions, representing a work of 5.139 kilogrammeters. After a cold bath at 50° F. for fifteen seconds the same group of muscles executed, before fatigued, seventy-four contractions representing a work of 9.126 kilogrammeters (Fig. 37 B.*). 1 Blfttter fUr klinische Hydrotherapie. (130) COLD TREATMENT 131 A graduated bath beginning- at 96° F. and ending- at 68° F. increased the number of contractions from thirty-nine, repre- senting- a work of 3.603 kilogrammeters , to eighty -seven con- tractions, the equivalent of 9.349 kilogrammeters of work (Fig. 38.}. When the muscles are already fatigued from active work, by cold applications they may be restored to their usual power. This restorative effect is well illustrated in Figs. 39 and 40. Fig. 36. Mosso's Ergograph. In Fig. 39 the first tracing (A) represents the fatigue curve of the normal muscle. The second (/?) is the fatigue curve taken following active work, i. e., at a time when muscular capacity has already been partially exhausted. The third trac- ing- (O shows the restorative effect of a graduated bath given following the fatig-ue of active work. In the case of the cold wet sheet rub following fatigue {Fig. 40C.} the muscular capac- ity has been increased to a point even above the normal. ist MUSCULAR CAPACITY With hot baths the opposite effects prevail. There is a de- cided lessening: of the muscular capacity, amounting in one of Kellogg's experiments to a decrease of 44 per cent. His ex- periments cover a wide range and are very instructive. He used both Mosso's ergograph and the dynomometer; the latter a machine of his own design. The following table is compiled from his experiments with Mosso's ergograph: — 2 Subject Hot Treatment Cold Treatment 21 140 26 150 Xot stated STRENGTH 4.994 Spr. 113° 5.395 1.312 D. 115° TIME 15 Min. 5Min. 4.432 0.927 Spr. 60° D. 60° D.55° 10 1 15 Min. Min. Sec. 6.094 6.925 1.527 26 151 8.282 I), 60° 3 Min. 11.966 26 151 6.371 Gen. D. 112° 15 Min. 4.155 Gen. I) 56° 15 Sec. 8.448 26 151 8.033 B. 104° 20 Min. 4.459 26 151 5.817 Gen. D. 55° 15 Sec. 8.642 26 151 5.817 Neutral bath 5.789 21 140 5.761 Shal. B. 65° 2 Min. 7.589 4.791 W. S. P. 60° 20 Min. 5.456 Fig. 37. Fatigue curve of right hand. A— normal, B— after bath at 50° F. for fifteen seconds. Considering both the dynomometer and ergograph experi- ments, there was, after cold procedures, an average gain in muscular capacity of about thirty per cent, and after hot appli- cations, an average loss of thirty per cent in the work accom- plished. Cold, therefore, increases the muscular working capacity; while warmth, not combined with mechanical effects, diminishes muscular power. After fatigue a simple warm bath may slightly increase muscular power, although this effect is 2 Recorded in Rational Hydrotherapy. MECHANICAL STIMULI 133 not decided (.Fig. 41 A.}. Warm procedures when combined with friction or percussion, as in douches, produce an increase in muscular power (fig-. 41C.), but to a less extent than cold. In practice alternate hot and cold douches, when so given that A B Fig. 38. Fatigue curve. A — before, B — after graduated bath,96°to6ff> F. A B C Fig. 39. Effect of work and graduated bath upon fatigue curve. A — normal, B — after active work. C — after work followed by bath. the hot is short and used only to prepare the body for cold, produce the greatest increase in the working power. Mechani- cal effects alone, such as massage, also raise the working" capacity of the muscles but to a less extent than cold proced- ures. 134 MUSCULAR CAPACITY To what are these tonic and restorative effects due? This question may be somewhat difficult to answer; but it would A B c Fig. 40. Effect of labor and cold wet sheet rub upon fatigue curve. A— normal. B — after labor. C — after labor followed by wet sheet rub. A B C Fig. 41. Effect of simple warm bath and of warm douche on tigued muscles. A— muscular fatigue followed by warm bath. B— after fatigue only. C— after fatigue followed by warm douche. seem that the restoration of the muscle to its normal working- power is due to more than one change. Among these changes may be mentioned the restoration of tone to the nerve and its FATIGUE POISONS 135 central cell brought about by the cold application. It is prob- ably due • also to washing out and oxidizing- of the fatigue poisons consequent on the quickening- of the circulation; and third to the return of the blood to a condition of more normal alkalinity. FATIGUE POISONS The last two of these changes deserve more than passing mention. Experimental fatigue due to contractions of excised muscle is accompanied by an increase of lactic acid, while freshly excised resting muscle yields very small quantities of lactic acid. So far as at present demonstrated lactic acid is the chief substance normally produced in fatigued muscle. This of course gives rise to a lessening in the alkalinity of the blood flowing from such fatigued muscles. In the presence of an abundant supply of oxygen this lactic acid disappears. We have already learned that these acidifying substances also dis- appear under the stimulus of cold procedures, due to an in- crease in oxidation. On the contrary, heating procedures are conducive to acidifi- cation as also already shown in the previous chapter. Con- firmatory of this is the following statement from Fletcher and Hopkins:3 ' The amount of lactic acid produced in full heat- rigor is constant for similar muscles. This 'acid maximum' of heat-rigor is not affected by a previous appearance within the excised muscle of lactic acid due to fatigue, or by a previous disappearance of acid in the presence of oxygen, or by alter- nate appearances and disappearances several times repeated." It is thus amply demonstrated that lactic acid is a fatigue poison. Procedures which cause its disappearance bring about, by this disappearance, a restoration or heightening of muscular power. On the contrary, procedures which increase the lactic acid content of muscles do by this increase bring on the phe- nomena of fatigue, and so lessen muscular capacity. There is some clinical evidence which goes to show that lactic acid is not the only substance which may cause the appearance of fatigue. Certain products of nitrogenous metabolism and 3 Quoted from "Further Advances in Physiology," edited by Leonard Hill, p. 214. 136 MUSCULAR CAPACITY particularly of the metabolism of nuclear proteid seem to exer- cise the same effect. Since the amount of these from the organism itself is small and fairly constant the effects are most apparent in the case of ingestion of much purin with the food (exogenous purin). The premature appearance of fatigue in meat eaters and users of coffee and tea is scarcely to be accounted for on any other basis. It is a well known fact that the fatigue curves of vegetarians reveal a high degree of ability to sustain continuous and pro- longed effort; while on the contrary the fatigue curves of meat eaters show a great susceptibility to fatigue, and hence its early onset in endurance tests. Buttner's recent compilation of u too CO/CTRACTlOnS AF-TEE ESO AF-Tee n V 5 , J '• ?s 5 X X a/i i 3"1 / ~ , ^ .5 3 m *- O ' y 3 ^- O / / • t-u on , 0 5 C / J ' < ^ 5 i / n ^ KB in s * : S : zjzo / 'S Hk o) IU i S £ J J / f ; i, G ^s "a d PC PC s | SO 0 ' § j r i B r? |S o 2 rift _8 7/1 « ; P ' " J 00 Figf. 46. Chart showing heat elimination by the skin as affected by various physical measures, thermic applications, etc. The following are some of the results claimed by Otto Pos- pischl as a result of his work as assistant to Professor Winter- nitz. (Fig. 46. Y 1. Displacing the blood and arresting the circulation in a part of the body lessens heat loss as much as 70.6 per cent. 5 Buxbaum— Lehrbuch der Hydrotherapie, II Auflage, p. 48. 150 THE HEAT MECHANISM 2. Hindering the circulation through the production of pas- sive hypcremia lessens heat loss as much as 46.2 per cent. 3. Mechanical irritation may occasion an increase of heat loss up to 95 per cent. 4. Weak chemical irritation produces an increase of heat loss to 40 per cent, strong irritation on the other hand a decrease up to 8 per cent. 5. Thermic influences which cause goose flesh decrease heat loss as much as 44.5 per cent. 6. A hot rain bath may through the production of goose flesh cause a lessening of heat loss up to 38.7 per cent. 7. Partial cold wet friction may raise the heat loss as much as 80 per cent. 8. Cold rain baths and rest following produce after a transi- tory decrease of heat loss an increase up to 23 per cent. 9. Cold rain baths with exercise following raise heat loss as much as 66.6 per cent. 10. Warm rain baths with cold fan douche and rest following raise the heat loss up to 16 per cent. 11. In two illnesses with increasing fever the heat loss was decreased as much as 25.4 per cent. SUMMARY Heat Production (Thermogenesis) The following are some of the conditions and measures that increase heat production: — Vital activities such as, — 1. Glandular activity. 2. Muscular activity. 3. Digestive activity. 4. Mental activity. External conditions, — 5. Reaction to cold applications (either long or short). 6. Friction. 7. Low atmospheric temperatures. 8. High atmospheric temperatures. SUMMARY 151 The following- conditions and measures decrease heat produc- tion:— 1. Fastingf. 2. Sleep and rest. 3. Reaction to short hot applications. Heat Elimination (Thermolysis) The following: conditions increase heat elimination; the agents or means which produce these conditions are listed as subordin- ates. 1. Dilated surface vessels and rapid circulation, — (a) Heat. (b) Short cold (reaction). (c) Friction. (d) Exercise. (e) Weak chemical irritants. 2. Increased perspiration (by evaporation of water),— (a) Heat. (b) Friction. (c) Exercise. (d) Water-drinking. 3. Increased rate of respiration. More or less prolonged applications of cold, whether cold water or cold air, abstract heat from the body by conduction; but they tend to make the body resist this effect; that is, it attempts to counteract heat elimination. The following measures, while they cause the body to make attempts at decreased heat elimination, do, by contact, abstract heat: — 1. Cold baths. 2. Cold enemata. 3. Cold water-drinking. 4. Breathing cold air. Conditions that decrease heat elimination: — 1. Contracted surface vessels and slowed circulation (as in goose flesh). 2. Decrease of perspiration (lessened evaporation). 15i THE HEAT MECHANISM 3. Decrease in volume of tidal air, slow or shallow respira- tion. 4. Very high atmospheric temperatures. 5. Oiling: of the skin. There are two local applications of cold whose chief effect upon the body temperature is not by the abstraction of heat. These are the ice cap applied to the head and the ice bag- applied over the heart. Their action is reflex. The former influences heat production through its reflex effect upon the thermogenic centers of the brain. The latter reflexly slows the heart beat and thereby the general circulation, which in turn decreases heat production. Of course, as previously stated, these effects are very slight in health but of inestimable value in febrile diseases. Heat Regulation (Thermotaxis) The normal temperature of the body is maintained by the nicety of the balance between heat production and heat elimin- ation. Increased heat production does not necessarily mean a rise of body temperature, since under normal conditions the heat is dissipated as rapidly as produced. The natural condi- tions that tend to increase heat production usually stimulate the elimination of heat as well, and so a balance is maintained. For example, the body is exposed to a draft of cold air. The skin assumes a goose flesh appearance by contraction of the involuntary muscles; it is. pale and contains less blood. While the cold air abstracts or conducts heat from the body, this less- ened circulation in the skin decreases the amount of heat lost from the surface. The perspiratory glands are less active, and the consequent lessened evaporation of water from the skin also decreases the amount of heat eliminated. At the same time the sensation of cold influences the thermogenic centers, and they cause the tissues to produce more heat. Even the shiver- ing which follows the exposure to cold, being muscular action, is one method of producing heat. Thus the temperature of the body is maintained at a con- stant point rather than lowered by the cold atmosphere. The converse is true of a short moderately warm bath. This would THERMOTAXIS 153 communicate heat to the body, and so tend to raise the tem- perature; but the body reacts in such a way as to preserve the balance. The skin is relaxed, the blood-vessels dilated and the perspiration increased, so that more heat is lost by dissipation from the surface. At the same time this relaxing effect causes loss of tone in the tissues generally, and so less heat is produced. These results are due to the control exercised by the heat-regu- lating centers before mentioned. It must not be supposed, however, that heat always decreases heat production. Very high temperatures markedly increase heat production, so much so that fatal poisoning may occur in such conditions as heatstroke. Serious cases never wholly recover from the effects of the high external temperature and the internal heat produced by it. They are ever after extremely susceptible to even the moderate heat of tropical climates or direct sunlight. While an agent may increase both heat production and elim- ination at the same time, one is usually increased to a greater extent than the other. For example, a cold mitten friction at first abstracts heat from the body, but the reaction causes increased heat production, as shown by the "warming effect." The increased circulation of the skin, which is part of the reaction, causes more heat to be lost. The total effect, how- ever, is an increase of heat in the body, because heat produc- tion is stimulated more than heat elimination. As we have seen, thermic applications produce decided changes in heat production and elimination. However, these changes do not, in health, produce wide alterations in the body temperature. On the contrary, the same influences applied in febrile conditions produce decided alterations. From the preceding experiments it will be seen that water at the varying temperatures and in the different ways in which it may be applied to the body, is capable of any and all possible variations and degrees of effect upon the heat mechanism . No possible alteration of heat production or elimination can be con- ceived of that water is not capable of producing. It is this versatility of application and effect that makes hot and cold water of so much service in fever and disturbances of the heat mechanism. 154 THE HEAT MECHANISM On the contrary, drug- action is particularly monotonous, and ideal combinations impossible to make. If they seem to act in a rational manner upon one part of the mechanism, it -will be found that they have an adverse action upon another part. And usually this adverse action more than outweighs any good which may be accomplished. There are no drug's which in- crease heat production by stimulating oxidation which are at all safe to use. Those drugs such as acetanilid and quinine, which decrease heat production, do so by a toxic action upon the thermogenic centers and tissues, so that there is an increase of the toxic products of metabolism rather than a decrease. On the other hand the drugs, such as alcohol and aconite which bring about greater heat elimination by dilating the surface vessels, accomplish this by paralyzing the *vasomotors, a result which is not only undesirable in fevers but often positively dan- gerous, as will be shown under the subject of fever and anti- pyretic effects. PART II THERAPEUTICS CHAPTER XV THE REALM AND LIMITATIONS OF PHYSIOLOGIC THERAPY THERAPEUTICS is the science and art of healing-. Dis- ease is an abnormal state of the body manifest in a morbid condition of structure or function. The departure from the normal nearly always begins in some mild way. Even in acute diseases the predisposition is laid in previous unhygienic habits or surrounding's. There are two general types of disease us- ually recog-nized, viz., the functional and the organic. In the former the actual structure of the diseased organ or part has not greatly deviated from the normal. The condition is mani- fest in a derangement of the function of the part. However, even in many so-called functional diseases it is possible, by careful microscopic examination, to detect more or less of pathologic change. But even in this case the alteration in structure has not gone on to such an extent as to preclude the possibility of a restoration to normal more or less complete. In the case of organic disease such gross structural changes have been produced as to be readily detected, and of such a character as to preclude the possibility of a return to the normal. In this case physiologic therapy can accomplish only aleviation of the symptoms and such building up of the general vitality and resistance of the patient as to more or less counterbalance the effects of the structural lesion. In many cases where no indispensable part is involved radical means may be used, such (155) 156 REALM OF PHYSIOLOGIC THERAPY as the removal of a malignant neoplasm, or some operation may de done to overbalance or palliate the results of the dis- ease, as in the case of Talma's operation for hepatic cirrhosis or Edobohl's operation for renal insufficiency. Purely func- tional diseases are, however, nearly always best treated by physiologic means. In the course of many diseases a point is reached beyond which a return to the normal is impossible without the inter- vention of some radical procedure. This is especially the case in inflammations. In certain grades, stages, and types of inflammation it is entirely possible, by natural means, to aid or affect the return to normal structure without the intervention of radical measures. This is true of such an inflammation as dry or serous pleurisy, pneumonia, or a simple surface infec- tion, but where these inflammations have gx>ne on to the formation of a suppurative focus or an abscess, physiologic means alone are unable to accomplish the full return to the normal condition. True, in time, the abscess mig-ht work its way to the surface, and so evacuate, but in most cases it is a long, tedious process and the patient is very much reduced in vitality by such delay, which delay may prove fatal from the absorption of toxic products. It is necessary, by some radical means, to accomplish the speedy evacuation of the pus and free drainage of the abscess cavity. The old dictum, ubi pus, ibi evacua, is just as true now as when it was first enunciated. Translated into terms of activity, it means, where there is pus, provide an outlet. It is necessary that evacuation be provided for. This, nature itself seeks to accomplish; but unaided, its attempts are accompanied by great destruction of tissue and much delay. By vigorous treatment, systematically applied, it is often possible to obviate the necessity for radical interfer- ence. But when the stage of suppuration has been reached or is. imminent, surgical intervention is just as much an assistant to nature as physiologic means and therefore just as rational. The same principles apply to the use of vaccines and anti- toxines. If the body has sufficient reserve power and the in- fection does not progress too rapidly, the system may provide adequate means of cure. Yet the course of certain infections RADICAL THERAPY 157 teaches us that such circumstances can not always be relied upon. Where available and of demonstrated value, no one would think of omiting the use of serum therapy. When it is used, physical means should not be left out simply because other procedures are more essential in a given case. All measures of value should be used in order to still further assist the body in combating" the infection. We may then, in general, say that where physiologic means are unable to aid the organism in reestablishing the normal structure and function, radical interference is necessary. This division line can best be determined by careful consideration of the usual trend of the particular disease in question. Experi- ence has shown that a certain type of inflammation in one organ or location may early tend to a serious issue, such as abscess or gangrene, while in another organ or location, there is less immediate danger, the inflammation tending to become chronic. For example, we may cite the case of appendicitis on the one hand and of salpingitis on the other. In both cases, physiologic means may accomplish a return to the normal, but in the case of appendicitis, this return is not to be relied upon for per- manent cure. The tendency is to recurrence and even, in a single attack, to perforation and peritonitis; while with the pelvic inflammation, physiologic means produce a safe issue which can better be relied upon for permanency; i. e., if taken early, there is little, or at least less, tendency to rupture and abscess formation. Even in the case of formation of pus in the tube, it is best to delay surgical interference until the acute inflammation has subsided and, if possible, the temperature has returned to normal. At best, it is dangerous and conducive to spread of infection if salpingectomy be done during the continuance of the acute inflammation. It is quite otherwise with appendicitis. Not only does opera- tion in the acute stage give good results, but because of the inability to determine the immediate issue, it is imperative to interfere as soon as possible. True, a patient may go through a number of acute attacks, all of which subside without serious complications, but this can not be relied upon to continue. In each succeeding attack there is greater liability to perforation. 158 Considering- all, we may, then, draw the conclusion that rational therapy is based upon three things, — experimsnt, ex- perience and judgment, — the latter for the purpose of apply- ing to the individual case the general laws and deductions relative to that condition. It requires an extreme nicety and perfect balance of judgment to determine whether a given border line case should be treated by physiologic or radical therapy. This faculty has been termed " surgical judgment." But its application requires more than a knowledge of operative technique. The surgeon who is pre-eminently a physician and whose armementarium is well stocked with physiologic means, will meet with the best success. Let not the surgeon be over enthusiastic about operative treatment nor the physician so confident of natural means as to procrastinate when prompt surgical interference offers the best hope of speedy and per- manent recovery. In some organic diseases the principle involved in physiologic therapy is that of calling into requisition certain vicarious functions, of stimulating structures which may relieve the diseased tissue or organ of part of its work. This is notably the case in valvular heart lesions and in the various forms of Bright' s disease. In valvular heart disease the blood-vessels may be made to assume much of the circulatory function and so relieve the central heart to that extent. To a limited degree the sweat glands may in Bright' s disease be made to supple- ment the work of the kidneys. We have already learned that the basic principle of physio- logic therapy lies in bringing into requisition the natural forces of the organism, of toning up and stimulating its natural powers of defense, making the body itself take part in its own healing. To do this most effectively the physician must become thor- oughly conversant with normal and abnormal physiology and spend his best efforts in studying the methods naturally pur- sued by the organism in defending itself against a given cause or pathogenic agent. These natural methods of defense we shall endeavor to point out in connection with the treatment of the various diseases which are amenable to physiologic therapy. PRINCIPLES OF THERAPY 159 BASIC PRINCIPLES OF THERAPY The philosophy of the practice of therapeutics is summed up in three things. The proper application of these may be con- sidered rational medicine. First, removal of the cause. Second, treatment of the existing conditions. Third, relief of such symptoms as, by their severity, in turn be- come causes. After removal of the cause many functional diseases right themselves (sublata causa, tollitur effectusY without further treat- ment, since perverted habits of function have not become fixed. In the large majority of cases in addition to the removal of the cause, it is necessary to direct attention to the existing perver- sions of function and structure. Usually, the measures found most successful in the treatment of a disease meet all three of these indications. It is, therefore, seldom necessary to direct treatment to each separately. For example, in typhoid fever the cold bath increases phagocytosis, thus combating the cause — infection; it relieves internal congestion; increases the oxida- tion and elimination of toxines; it relieves the nervous symp- toms; sustains the heart and circulation; and lessens the fever. A single procedure meets all three indications and thus proves itself the summum bonum of therapeutics in the treatment of this disease. The same is true of many other diseases. 1 When the cause is removed, the effect disappears. CHAPTER XVI FEVER AND ANTIPYRETIC EFFECTS CAUSES AND SYMPTOMS OF FEVER FEVER is a disturbance of the heat mechanism in which there is a more or less prolonged rise of temperature above the normal. The principal cause is the circulation of unusual toxic substances in the blood. It is the result of a protective effort, an attempt on the part of the body to cope with these poisons; but the organism may be overwhelmed by them and so be unable to oxidize them with sufficient rapidity to protect the body. Or, because of the nature of these poisons, the heat- regfulatingf centers and the vasomotor centers are disturbed and the balance unsettled. If heat elimination were to keep pace with the heat production, even though the latter were greatly increased, there could be no rise of temperature. Many toxines cause a sensation of chilliness and tlrus decrease the heat loss, and fever results. While the body attempts to protect itself, its efforts are not always well directed or governed. The poisons producing pyrexia are of various origin. They may be formed in the body or introduced from without. In the former case the toxemia may be due to the accumulation of body poisons, i. e., those which are normally produced in health by ordinary metabolism, but are usually eliminated as fast as formed. These poisons are called leucomaines . They do not produce the higher types of fever, nor fever of long duration. The poisons due to anger, worry, and other nervous disturb- ances are classed under this head, although they are not normal to the body. Prominent among the leucomaines, as a cause of fever, are the purin bases. Apropos of this subject we quote the follow- ing from Lusk: — ' 1 Science of Nutrition. 1906. p. 267. (160) CAUSES OF PYREXIA 161 " However, there is a very noteworthy record made by A. R. Mandel that the rise of temperature in aseptic or surgical fevers is accompanied by a largfe increase in the purin bases in the urine of patients fed with milk. The temperature rises and falls with the quantity of purin bases eliminated. The uric acid elimination is reduced. ' That the purin bases can be the cause of the rise of tem- perature is indicated by the experiments of Burian and Schur who found that when nucleoproteid was administered intraven- ously to a dog- a rise of temperature followed. Mandel showed that a subcutaneous injection of 40 milligrams of xanthin caused a marked rise in the temperature of a monkey, and that the administration of a strong decoction of 60 grams of coffee (con- taining trimethyl-xanthin) to a man unused to coffee-drinking, was followed by a febrile temperature." Toxines may be produced by saprophytic bacteria (those of decomposition), growing in the body or in the alimentary tract. These conditions are known as sapremia and auto -intoxication. Foods decomposed by bacterial action may serve as the source of poison, as in the eating of decomposed meat, cheese, etc. Such products of bacterial decomposition are known as pto- maines. Bacterial toxines produced by pathogenic bacteria, growing within the body itself, are the most usual causes of fever and those with which we are most concerned in the treat- ment of this condition. Ultimate Causes of Pyrexia. The following outline is modi- fied and abridged from Sollmann.2 Fever may be due to, — 1. Exposure to excessive external heat as in sunstroke. Also internal heat (over-oxidation) as in excessive muscular exercise. 2. Certain drugs, such as the convulsants, cocaine and strych- nine, by the production of convulsions or spasm of the muscles. 3. Toxic proteins. (a) Bacterial toxines of infectious diseases. (b) Ptomaines. (c) Auto-intoxication (intestinal, biliary, urinary, etc.). 2 Text Book of Pharmacology. 1901, p. 394. 11 162 FEVER AND ANTIPYRETIC EFFECTS (d) Absorption of unconverted digestive products, as albu- moses and peptones in a- diet too rich in proteid; or due to digestive disorders. Manifestations of Fever. In addition to the causes of fever, it is necessary to consider the symptoms, since these are an indication of the real condition of the patient and may be of such a magnitude as, in turn, to become a cause of additional trouble; in which case, special treatment must be directed toward their relief or palliation. The toxines, or the high temperature, cause the following symptoms, recognized as characteristic of fevers: — 1. Nervous disturbances, such as malaise, headache, back- ache, insomnia, delirium, etc. 2. Hot dry skin, or cold clammy skin. •3. Increased pulse rate and blood tension. 4. Increased rate of respiration. 5. Excessive thirst. 6. Loss of appetite, foul breath, coated tongue. 7. Constipation. 8. Urine scanty, highly colored, high specific gravity, in- crease of urea. PRINCIPLES OF TREATMENT Since oxidation is one of the means of getting rid of toxines, this burning is to be encouraged rather than hindered. The fever should be controlled, not combated. The system is to be aided in its attempt to oxidize and eliminate the poisons. This is where failure in the protective mechanism is especially mani- fest in febrile diseases. While the decomposition and destruc- tion of body tissue is much increased in fever, true oxidative changes are nearly always decreased. For this reason the system is compelled to cope not only with the toxines of direct bacterial origin but also with those of decomposition and incom- plete metabolism. The idea that the reduction of temperature is the sole object in the treatment of fevers has become so firmly fixed in the minds of physicians and laymen that it is hard to eradicate. It was this idea that led to the use of the medicinal antipyretics, 163 the giving' of which is not only wholly irrational , -but productive of very serious complications and sequellae. To a great extent, the same idea also prevails with regard to the use of the cold bath in fever, much to the discredit of hydrotherapy and rational therapeutics. Many, too, regard the reduction of fever as the only asset of hydrotherapy, and fever as the only condition in which hydriatic measures are applicable. That both ideas are erroneous has already been shown and will be made plainer as we consider the rationale and results of hydrotherapy, not only in fever, but in a host of other maladies. The basic object in the treatment of fevers is the same as in all other diseases, viz., the removal of the cause. This can be accomplished only by decreasing the toxemia. In only a few febrile diseases has medical science discovered a direct anti- toxine or perfected a workable system of producing immunity. We are, therefore, under the necessity of directing our efforts toward increasing the oxidation and hastening the elimination of these bacterial toxines; increasing phagocytosis; and assist- ing and conserving the powers of the tissues in the production of antitoxines, antibodies, opsonin, etc., this latter action being largely the work of the phagocytes themselves, upon the integ- rity and activity of which immunity depends (Metchnikoff). In addition to this basic object — the removal of the cause — it is necessary to prevent the over accumulation of heat, a thing which is accomplished by the same means. And third, to miti- gate the symptoms, especially those referable to the nervous system; combat headache, malaise, insomnia, delirium, etc. This also is done by the cold bath and other cold applications. In fact, all of these results can be and are obtained by properly applied hydriatic measures as has been demonstrated by the experiments cited in the previous part of this work. RATIONALE OF HYDROTHERAPY IN INFECTIOUS FEVERS The principal object to be sought in the treatment of fever is the combating of the infection. The antiseptic treatment of infections has proven a failure. There are no germicides known which have given anything like even moderate success 164 FEVER AND ANTIPYRETIC EFFECTS in dealing with bacteria. A few like hexamethylenamin are valuable aids, but of limited range. The chemical destruction of bacteria within the human organism is a disappointment and, as remarked by one, " we aim at the germs and hit the patient. ' ' The organism is hindered more than it is helped. Concerning methods of treating infections W. J. Mayo3 has the following to say: " Experience soon taught us, however, that in combat- ing infectious disease, it is even more important that we famil- iarize ourselves with those conditions of the body by which nature combats disease." Upon the physicians knowledge of these natural methods depends to a large extent his ability to employ physiologic therapy in a rational way. The body itself must be aroused to combat the infection. This is most effectually accomplished by those means which increase the vital resistance of the body, conserving its power, and especially by those means which increase the number and efficiency of the phagocytes. It has already been shown how this may be accomplished. It will also be noted that cold applications as suited to the varying needs of different diseases, compass all of these results. We have seen that cold produces a leucocytosis, restores the diminished alkalinity of the blood, produces an active arterial hyperemia, increases and sustains blood pressure, so that life giving, energizing blood circulates more rapidly where previously there was stasis, venous hyper- emia, leucopenia, lowered alkalinity, and a blood laden with leucomaines, toxines, and acid poisons. The elimination of toxic products of bacterial life is hastened and their oxidation increased by cold. The phagocytes and body tissues are so energized that the histogenous production of antitoxines, bac- teriolysins.opsonin, etc., is increased. While all these changes are being brought about, the lessened toxicity of the body fluids relieves the nervous system and it is quieted and invigorated by the tonic influence of the cold. Restlessness, insomnia, or delirium gives way to clear coordinated action or undis- turbed sleep. The hot dry skin, or the cold clammy skin, is replaced by the warm moist surface. This remarkable group of changes, all of which are beneficial and derived from a single 3 Mayo Clinic. 1910, p. 118. TOXIC VASOMOTOR PARALYSIS 165 agent — cold water — it is impossible to bring about by any other known therapeutic agent or combination of agents. It is simply unique in the realm of therapy. Toxic Vasomotor Paralysis. Further in regard to the con- nection of the circulatory system with the general manifesta- tions of fever and especially with regard to the circulatory complications which contribute so largely to the mortality, experimental pathology has laid a very firm foundation for the use of hydrotherapy in fevers of infectious origin. The researches of Romberg and Passler are considered the basis of our knowledge of the state of the heart and blood-vessels in these diseases. The reports of their work 4 have shown con- clusively that circulatory failure is not primarily due to the heart itself, but to paralysis of the blood- vessels, brought about by damage to the vasomotor centers. In this connection we can not do better than quote from the brief resume of these researches given by Janeway and from remarks made by Forchheimer.5 ' They studied the fatal collapse which occurred in rabbits after infection with the pneumococcus, the bacillus pyocyaneus, and the diphtheria bacillus; the first producing a true septi- caemia, the latter a local lesion with general toxaemia. All of the 250 animals used were autopsied, and the heart and other important organs examined microscopically. Their method consisted in observing the mean carotid pressure at different stages of the disease, and the effect upon it of (l) abdominal massage, which increased the work of the heart by supplying it with more blood; (2) compression of the aorta above the diaphragm, which makes the work of the heart maximal; (3) irritation of the nasal mucous membrane with a Faradic current, which causes extreme reflex vasoconstriction; and (4) short asphyxia (thirty seconds) , which acts similarly only on both medullary and spinal vasomotor centers; while sensory stimulation affects only the center in the medulla. They reasoned that, should there be no rise in pressure from sensory 4 Rombsrg and Passler— Deutsch. Archiv. fur klin. Med., 1895, LXIV, pp. 652—763; also Passler— Mum-hen. Med. Wochenschrift, 1901, XLVIII. No. 8. 5 The Clinical Study of Blood Pressure, pp. 155, 156; and Cardiac and Vascular Com- plications in Pneumonia— Journal of American Medical Association, Oct. 30, 1909, p. 1450. 166 FEVER AND ANTIPYRETIC EFFECTS irritation or suffocation, while abdominal massage and ligature of the aorta still called forth a well marked one, then the heart must be functionally capable and the vasomotor mechanism paralyzed. To determine whether the central or peripheral vasomotor mechanism was at fault, they used injections of barium chloride, which cause constriction of the arteries by purely local action upon them. ' ' Their experiments showed that the blood pressure and the response to all the procedures remained perfectly normal throughout the early stage of the disease, being unaffected by the fever. The greatest elevation of pressure was obtained on stimulating the mucous membrane of the nose. When the animals showed signs of impending collapse in their behavior, the blood pressure, though still normal, began to sink, while the heart beat more forcibly. Hand in hand with this went a great reduction in the rise of pressure from sensory irritation, a moderate decrease in the asphyxial elevation, but as high a pressure as before after abdominal massage. In many cases the pressure did not fall until the reflex rise had been almost abolished, evidently being maintained by increased cardiac energy, in spite of the vascular dilatation. Finally in complete collapse, which developed very rapidly, the aortic pressure fell to the lowest level, as after destruction of the spinal cord; no reflex rise could be obtained, but abdominal massage gave an immediate elevation. It was evident, therefore, that the circu- latory disturbance at the height of the infection depended absolutely upon a paralysis of the vessels, not upon any damage to the force of the heart. ' ' As regards their reaction to compression of the thoracic aorta, the diphtheria animals showed a divergence from the pneumococcus ones; the latter evincing practically normal cardiac reserve force, while the former showed a distinct fall- ing off. Anatomically, also, the diphtheria hearts had suffered damage, parenchymatous degeneration being well marked, as in clinical diphtheria. The pneumococcus animals had scarcely any change in their cardiac muscle. Thus evidence of weak- ness in the heart muscle in diphtheria was of minor importance, the real cause of death in all cases being the complete loss of TOXIC VASOMOTOR PARALYSIS 167 vasomotor tone. By intravenous injections of barium chloride they proved decisively that this was due to central paralysis. Their conclusions were, that all three organisms used damage the circiilation through paralysing the vasomotor centers throughout the medulla and cord; this vasomotor paralysis leads to a fall in blood pressure, and further, to a changed blood distribution; the splanchnic circulation is overfilled, the brain, muscle, and skin vessels are empty; the heart is not affected, except secondarily through insufficient blood supply." Forchheimer's discussion on this latter condition — splanchnic congestion — is as follows: "Long ago it has been shown in animals, that on section of the splanchnic nerve, an enormous quantity of blood accumulates in the intestine, which is followed by intense anemia in other organs, especially in the central nervous system, which may cause death. The splanchnic nerve is the vasomotor nerve of the intestines, and its section causes paralysis of vasomotor function and enormous dilatation of the blood-vessels. In paralyzing the vasomotor center with the pneumococcus the same result follows in man. In brief, in man there is first, dilatation of blood-vessels in the splanchnic area; the blood pressure which sooner or later is normally low in pneumonia, sinks; the heart, which is supplied by an insuf- ficient quantity of blood, which is gradually becoming station- ary in the affected area, continues to draw blood from other places, the liver, the skin, the muscles and central nervous system, and becomes more and more rapid and ineffectual, 'bleeding itself into the splanchnic area,' and finally stops. The intracardiac pressure is reduced so that the myocardium ceases to contract, moreover, the various cardiac and vasomotor centers become asphyxiated, and therefore paralyzed." By reference to the chapter on blood pressure in the first part of this work it will be seen that the above quoted facts and discussion very clearly demonstrate the rationale of hydro- therapy in infectious diseases, and clinical experience has proven what experiment has demonstrated. The vasomotor stimulation which results from hydriatic procedures amply meets the needs of the situation, which need it is impossible to meet by medicinal therapy of any sort. 168 FEVER AND ANTIPYRETIC EFFECTS THE EFFECTS OF MEDICINAL ANTIPYRETICS /. Drugs having a Collapse Action, such as Aconite and Viratnun Viride. These lessen the force of the heart beat and dilate the blood-vessels, so lowering the blood pressure. Heat production is decreased, because of this latter action. Vasodilatation favors the loss of heat from the skin. This is not a tonic but an atonic dilatation and so, in no way restores the lost tone to the circu- latory system. Both these drugs decrease fever at the expense of the heart's action and so prove dangerous in asthenic fevers, or where there is cardiac weakness, dilatation, or incompetency already existing. 2. Alcohol. The only beneficial (?) action of alcohol, as re- lied upon in fever and as given in so-called therapeutic doses, is upon the smaller blood-vessels, in which it causes an atonic or paretic dilatation and consequent loss of heat from the skin. At the same time, it dilates the visceral capillaries which arc already congested in febrile conditions. Their paretic condi- tion renders the viscera much more liable to suffer from retro- stasis when the body is exposed to cold. Alcohol decreases metabolic processes and oxidation.6 The tissues are less active so that toxines, instead of being more rapidly oxidized and eliminated, tend to accumulate in the system. Alcohol lessens the phagocytic activity, — the natural defence against infection, and discharges immunity. Delearde has shown that the ab- sorption of alcohol is a grave obstacle to immunization against hydrophobia. Abbot, in experimenting on animals, proved that those subjected to the influence of alcohol were more sus- ceptible to the harmful effects of streptococci, bacillus 'coli and other bacteria. Both Delearde and Laitinen found it impos- sible to vaccinate against anthrax, animals that had been given alcohol on several successive days. • 3. The Coal Tar Products, as Acetanilid, Phenacetin, and Anti- fyyrin. These decrease heat production by the direct toxic action of their aromatic radicles on the heat centers in the "Alcohol in excessive doses and prolonged anaesthesia both paralyze the heat-regu- tianism A man who is 'dead drunk' resembles a cold blooded animal; ex- to cola produces not an increase but a decrease in combustion, and his tempera- tlily falls. It is not surprising, therefore, that death from exposure chiefly oc- e case of intoxicated persons." (Hutchison— Applied Physiology. 1908, p. 67.) MEDICINAL ANTIPYRETICS 169 brain and on the processes of oxidation and proteid metabolism.7 This is shown by the decrease in tissue destruction, lessening of urea, etc. This effect is most marked in fever, where the rational procedure is to increase the burning1 up of poisons, (purins, toxalbumens, bacterial toxines, etc.) in order to get rid of them. Neither do these drugs increase the elimination of poisons. They are very powerful cardiac depressants and possess a decided collapse action. This is most marked with acetanilid. They cause breaking up of the red cells with the formation of methemoglobin, thus in a second way, preventing oxidation by limiting the oxygen-carrying capacity of the blood. The movements of the whites are arrested. Phagocytosis is prevented. This is another example of drugs that render the body less able to resist infection. 4. Qidnine. This drug lowers temperature by decreasing heat production. Its action is said to be chiefly peripheral upon the thermogenic tissues, in decreasing nitrogenous met- abolism. This decrease may reach as high as 39 per cent with large doses.8 The drug probably owes its toxicity to its aromatic nucleus, the same as the coal tar products. It not only hinders the destruction of nitrogenous toxines, but is a powerful poison to the phagocytes, arresting their movements immediately on contact with them. This result obtains when only 0.5 to 1 part in 1000 of solution is used. A somewhat larger dose causes their destruction (Binz, Sollmann). Accord- ing to recent experiments by Man waring and Ruh, larger amounts than 0.008 per cent of quinine cause complete sup- pression of phagocytosis. Since 1-13 of the body weight is blood, an individual weighing 130 pounds possesses 10 pounds of blood, totalling 70,000 grains. If, at any one time, there should be in the blood of a person of this weight, ten grains of quinine, there would then be acting upon the phagocytes an amount nearly double the minimum toxic dose. Quinine fre- quently causes hemoglobinuria. Metchnikoff9 makes the fol- lowing statement: "It is not only opium and alcohol which 7 White and Wilcox— Materia Medica and Therapeutics, 1900, p. 300; also Sollmann— Text Book of Pharmacology, 1901, p. 355. , , t Book of Pharmacology, 1901, p. 355. Sollmann— Ibid, p. 346. See also Adami— Inflammation, 1907, p. 152. New Hygiene, p. 28. 770 FEVER AND ANTIPYRETIC EFFECTS hinder the phagocytic action. A number of other substances regularly employed in medicine, cause the same results. Even quinine, the . . . effect of which in malarial fevers is indisput- able, is a poison for the white blood cells. One should, there- fore, as a general rule, avoid as far as possible the use of all sorts of medicaments, and limit one's self to the hygienic measures which may check the outbreak of infectious disease. This postulate further strengthens the thesis that the future of medicine rests far more in hygiene than therapeutics." 5. Diaphoretics, as Pilocarpin and .Dover's Powder. These lower febrile temperature by producing sweating. This in itself, is not irrational. In the case of the former, it has recently been shown that this is at the expense of the heart's action. The latter drug contains opium which has the same action on the phagocytes as alcohol, quinine,, and coal tar pro- ducts. 6. Refrigerants, such as the Alkaline Citrates, Organic Acids, and Add Organic Salts. The alkalescence of the blood is diminished in auto-intoxication and infectious diseases. Bou- chard failed to neutralize the excess of acid in the blood by the administration of inorganic alkalies. The citrates, tartrates, etc., do, however, favor kidney activity (diuresis) and sweat- ing (diaphoresis), and so aid in the elimination of toxines. Experience demonstrates that the natural fruit juices, contain- ing these acids and "their salts, give better results in these respects than artificial preparations and do possess a true re- frigerant action. No great discernment is necessary to decide that antipyretic drugs are harmful in fever. The majority of fevers are due to infections, i. e., are bacterial toxemias. These drugs in no way remove the cause, nor do they assist the body to over- come the infection. On the contrary, they destroy or cripple the agents of natural defense — the leucocytes, rendering them an easy prey to bacteria. ANTIPYRETIC EFFECTS OF THERMIC APPLICATIONS Let us now turn our attention to the differences in the effects of the various thermic applications used in the treatment of fevers. The following classification will be found helpful: — HYDRIATIC ANTIPYRETICS 171 1. Applications of cold. (a) Prolonged — direct antipyretic, by abstracting more heat than is produced. (b) Short — stimulate heat production as much or more than they increase heat elimination. 2. Applications of heat. (a) Prolonged — antipyretic by increasing heat elimination through profuse sweating. (b) Short — an adjuvant, prepares the body for cold appli- cations. The physiologic effects of the four classes may be studied under the two following heads: — 1. Effect on heat production. 2. Effect on heat elimination. Prolonged Cold. The Brand bath may be taken as a type of this class of hydriatic antipyretics, the effects of which are as follows: — 1. Heat production is decidedly increased. This is due to the thermic stimulus arising from contact with the cold water. Oxidation and nitrogenous metabolism are both increased. There is not only an increase in the oxidation and consequent destruction of poisons, but their elimination in an incompletely oxidized state is hastened. This is proven by the decided in- crease in the toxicity of the urine after a cold bath, as shown by Bouchard, Roque and Weil. 2. Heat is transferred from the body to the water and in greater quantity than the heat produced, so that a fall of tem- perature results. This is made doubly necessary because of the above mentioned increase in heat production which would tend to increase the height of the fever if it were not combated . This is by purely mechanical means, i. e., conduction. The heat of the body is transferred to the water which will take up an exceedingly large amount without being greatly warmed. Heat elimination is increased by friction, i. e., the body is constantly kept in a condition favoring the abstraction of heat. The rubbing produces vasodilatation and quickens the circula- tion. These conditions bring more blood to the surface which is exposed to the cold water. The same conditions and the 172 FEVER AND ANTIPYRETIC EFFECTS friction itself serve to give a sensation of warmth to the skin and so prevent chilling: and the resulting: retrostasis of blood. Indications. These effects are indicated in long- continued asthenic fevers, such as typhoid, typhus and in hyperpyrexia. The treatment must be frequently repeated over a considerable length of time, since it can not be hoped that the source of tox- emia will be eradicated by a few applications. Short Cold applications are almost always accompanied by mechanical stimuli. The cold mitten friction is the best ex- ample of this class. 1. Heat production is increased by reason of the action of the thermic and mechanical stimuli on the heat centers. 2. The contact with the cold water is of too brief duration to abstract much heat from the body. The cooling is not mani- fest except on the skin. Later, heat elimination is increased because of the vascular reaction in the skin. Indications. Short sthenic fevers, as grippe, colds, etc., or where the skin is cold and clammy, for the purpose of warming the skin and raising the blood pressure. This sometimes occurs in typhoid. Long Hot. Any of the sweating treatments used in fevers serve to illustrate the effects of this class of measures. 1. Heat production is increased during the treatment at least to some extent. The atonic reaction which follows may result in decrease of heat production. 2. Heat is communicated to the body. This is the chief cause of the initial rise of temperature before perspiration becomes well established and general. Later, heat elimination is enormously increased because of the increased circulation in the skin and especially by the evaporation of the perspiration. This latter is the essential effect of sweating treatments. Indications. Sweating treatments are indicated in the first stage of nearly all fevers, /. e., at the onset. It is at this time that the initial chill occurs. They are useful at this stage in such fevers as measles, influenza, scarlet fever, etc. Short Hot. Fomentations, short hot packs, hot sponging, and the hot evaporating wet sheet pack are examples of this HYDRIATIC ANTIPYRETICS 173 class of antipyretics. Their special advantage is the preparing of the skin to properly react to succeeding cold treatment. The skin is warmed and heat elimination is increased through the warming effect. Some heat is communicated to the body. Heat production is little, if at all influenced. Wherever there is chilliness, cyanosis, or goose flesh in febrile disease, some form of hot application must be used before resorting to cold, since in the absence of the former, the cold may have a de- cidedly adverse effect. In addition to the effects noted in the general classes of treat- ments discussed above, it should be understood that by proper variations in the manner of giving hydriatic treatment, it is possible to produce any desired effect upon the heat mechanism Temperature-raising value. D F W H R C M F C T R WS R Brand Cold Bath Bath Temperature-lowering value. Fig. 47. Diagram showing quantitative relation between the temperature-raising and the temperature-lowering capacity of different treatments. and upon febrile temperature. In the case of cold treatments these variations are produced by changes in the degree of friction used and in the quantity of cold water brought in con- tact with the skin surface. The more the friction and the less the contact with cold water, the greater the temperature-raising capacity. The larger the amount of cold water brought in contact with the body, provided reaction be maintained, the greater the temperature -lowering capacity. This relation is graphically shown in Fig. 4-7 . The proportion of each block below the cross line indicates the relative value of the treatment in lowering temperature as compared with its temperature- raising value indicated by the proportion of the block above the line. 174 FEVER AND ANTIPYRETIC EFFECTS THE HEAT MECHANISM IN FEVER The mechanism of the production of fever is a large subject and one somewhat outside of the scope of this work. The re- are, however, a few points that should be noted in order to grain an understanding; of the principles involved in the treatment of fever, /. e. , in order to treat such conditions intelligently . Graham Lusk 10 gives the following discussion : — "A high fever may be accompanied by an increased metabol- ism of only 15 per cent. The cause of the fever must therefore be due to diminution in the ability to discharge the heat pro- duced. In further support of this, Senator has shown that the fever following pus injections in a dog begins with a retention of heat within the body. Nebelthau found that when the heat discharge of a normal rabbit was called 100, during the first twelve hours of infection in which the temperature rose from 38.6° — 40.1°, the discharge of heat was but 96.3. Assuming the heat production to have been the same in these two periods (as was actually the case in the rabbits of May), then the heat retained would account for the pathological increase in tempera- ture. At a later stage the discharge of heat rose to equalize its production at the higher temperature." In the state of lessened heat elimination manifest at the beginning of most fevers lies the reason for the initial use of hot applications so frequently advised in the subsequent pages of this work. ' Nebelthau has shown a fall in temperature and heat pro- duction in a rabbit whose cord was divided between the sixth and seventh cervical vertebrae, and has also demonstrated that under these circumstances infection with erysipelas of the pig had no influence on temperature or heat production. The in- ference is that the febrile toxines act through the higher vaso- motor centers, whose regulatory control is lost in the above experiment. ' A kindred interpretation may be placed on the experiments of Mendelsen, who was unable to produce fever through pus injections when the dog was under the influence of chloral or morphine, although such treatment in a normal animal caused 10 Science of Nutrition, p. 255. HEAT MECHANISM IN FEVER 175 a rise in temperature of from 36.3° — 39.9° in forty-five minutes. Mendelsen also finds a constant constriction of the renal blood- vessels in fever. "in intermittent fever profuse perspiration is certainly an important factor in the reduction of temperature at the end of the febrile stage. "It may be concluded, as Krehl emphatically states, that insufficiency of water evaporation plays a not unimportant role in the febrile rise in temperature. The body might be cooled were the sweat glands freely active. 1 The production of heat in fever may be greatly increased during a chill, and a rapid rise in temperature may follow. This was shown by Liebermeister in a case of malaria. The temperature rose from' 36.9° in the first half hour to 39.5° at the end of another hour, while the carbon dioxide expired rose from 13.85 grams to 34.20 grams per hour. This was a case of chill with shivering. This increased metabolism is due to the mechanism of chemical regulation. The blood is driven from the skin by vasoconstriction, those end-organs of the skin which are sensitive to cold are strongly stimulated, with the result that there is a reflex increase of heat production. That this is true is shown by the fact that if the cold stimulation be removed by supplying a warm environment, the attending phenomena pass off (Krehl)." VARIATIONS THAT PRODUCE FEBRILE TEMPERA- TURE AND THEIR RELATION TO TREATMENT Any unbalancing of thermo-regulation whereby there is more heat produced than is eliminated will cause a rise of tempera- ture. It will be seen from this that there are several possible variations in these two elements which might be the cause of fever. In a majority of fevers the greater difficulty at first is in the faulty heat elimination. A rise of temperature will fol- low any of the conditions listed below: — Heat Production Heat Elimination 1. Increased - normal 2. Increased increased, but less than heat production 3. Increased - decreased 4. Normal - decreased 5. Decreased decreased, but more than heat production 176 FEVER AND ANTIPYRETIC EFFECTS Clinical Antipyresis. These variations are, perhaps, largely of theoretical interest. However, there is a practical applica- tion to be made of the signs and symptoms which indicate a decided over-production of heat or a marked decrease in heat elimin- ation. The former centra-indicates vigorous tonic measures, such as the cold mitten friction, which are not accompanied by heat abstraction, i. e., more or less prolonged contact with cold water. The latter are of especial importance in revealing a con- dition which absolutely centra-indicates the use of long cold applications, and in many cases even the short cold friction un- less preceded by hot applications. In cases of pyrexia the following signs indicate a great increase in heat production: — 1. Full pulse and flushed face. 2. A hot dry skin. A consideration of these will at once reveal the fact that a cold mitten friction would be inappropriate, since it has no tendency to lower blood pressure, also because the treatment stimulates heat production; but the contact with cold water is of too brief duration to abstract much heat from the body. Neither would a hot application or a sweating treatment best meet the condition. It is necessary to abstract heat from the body by some more or less prolonged cold application. On the other hand, the following symptoms show a decided decrease in heat elimination: — 1. Cold skin, whether dry, or moist and clammy. 2. Cyanosis. 3. Goose flesh appearance. 4. Chilly sensations. 5. Shivering. Again, consideration of these conditions reveals the fact that cold applications, unless accompanied by vigorous friction, and not even then in some cases, will greatly increase the anemia of the skin and the internal congestion which exists because of the chilling. In these cases hot applications or sweating treat- ments must be used until the cyanosis is overcome and the blood brought back to the surface, thus relieving the internal congestion and, at the same time, imparting a sensa- tion of warmth to the body and consequently checking the THERAPEUTIC CLASSIFICATION 177 shivering'. This is also indicated in the first stage of many fevers where the chill has actually begun or where chilly sen- sations indicate its approach. In this case the hot sweating- treatment should not be repeated, at least not frequently, as it .is too weakening. Its frequent repetition does not increase the vital resistance, but rather decreases it. It decreases phagocy- tosis and the production of antibodies. Malaria is an exception to the general rule of the use of hot treatment at the onset. Here it is a detriment rather than a benefit. On the other hand, in acute nephritis much sweating treatment should be used all through the course of the disease. . In general then, it may be said that long cold applications should be used where great increase of heat production is the chief cause of fever; and hot applications where the decided decrease of heat elimination is a prime factor in the fever. Symptoms Chief condi- tion present Indications Table of Therapeutic Classification Group A Group B Full pulse, flushed face, Cold skin, wet or dry, hot dry skin cyanosis, goose flesh, shivering Great increase in heat production Abstract heat by long contact with cold Treatment Long cold applications A decided decrease in heat elimination Warm the skin, combat internal congestion Hot applications until blood is brought back to skin The following lists of hot and of cold treatments are those that are most useful in fevers. When properly selected and suited to the individual case, the cold treatments meet the first indi- cation and the hot treatments the second indication. Cold applications useful in febrile conditions: — 1. Brand bath. 2. Graduated bath with friction. 3. Tepid or cool bath. 4. Evaporating wet sheet pack. 5. Cold towel rub. 12 178 FEVER AND ANTIPYRETIC EFFECTS 6. Ice rub. 7. Cold sponging-. 8. Cold affusions. 9. Cold to head and neck. 10. Ice bag or cold compress to heart. 11. Cold compress to abdomen. 12. Cold water coils to head and abdomen. 13. Cold rectal irrigation or enema. 14. Cold water drinking. 15. Fresh cold air in the sick room. Hot applications which may be used to reduce fever or assist the cold applications: — 1. Hot blanket pack. 2. Hot bath (very short). 3. Hot evaporating sheet. 4. Hot sponging. 5. Fomentations to spine. 6. Fomentations to abdomen. 7. Hot water drinking. 8. Cold mitten friction (reaction simulates the effects of a hot application). CHAPTER XVII THE TREATMENT OF FEVERS TYPHOID FEVER TYPHOID fever is an acute infectious disease, more or less self-limited, characterized pathologically by a localized inflammation of the lymphatic structures of the intestines and a general distribution of the bacteria (bacteriemia) ; clinically, by fever of rather long1 duration which, at the onset, rises gradu- ally in stepladder-like increase and gradually subsides; diarrhea, and a special tendency to hemorrhage and perforation. We say that the disease is self-limited because it is one of those infec- tions which arouse the body to the production of antitoxines, bacteriolysins, ag-glutinins, etc., so that when the system has had time to produce these, the infection is overcome and the patient recovers. It is not possible to abort typhoid fever by therapeutic means. The so-called abortive type of typhoid fever is due to some peculiarity of the individual or of the infection and not to any treatment. The chief object to be accomplished in the treatment of typhoid fever is not the reduction of the temperature, but the sustaining- of vital resistance until such time as the system has had opportunity for the production of antibodies. This build- ing- up of vital resistance is accomplished chiefly in two ways:— first, by increasing- the efficiency of the protective mechanism. This is accomplished by stimulating- the process of phagocy- tosis, i. to leslons of tne blood-making organs."— Edward s Practice of Medi- (lilt*, 1VU/, p. llo. MALARIA 201 after the beginning of the treatment. At the end of a week the blood was free from plasmodia. As in other fevers, the rationale of these measures is not difficult of explanation. It has been shown by Maragliano 10 that contraction of the surface vessels in malaria begins two hours before the temperature begins to rise and about three hours before the paroxysm (Fig. 49.}. The skin vessels continue to 105.8 102.2 100.4 98.6 Fig. 49. Chart showing the causative relation of peripheral vasocon- striction to the fever and chill in quotidian malaria. P — state of peri- pheral blood-vessels as shown by the plethysmograph, T — tempera- ture. (Maragliano.) contract, and the fever reaches the highest point wrhen the vessels are in a state of maximum constriction. During the sweating stage the vessels dilate, and when maximum dilata- tion is reached the temperature returns to normal. During the two hours referred to, the constriction of the skin vessels and anemia of the skin becomes well " fixed," so that a severe pro- longed chill is provided for. At the same time there is ' an enormous retention of heat due to the failure in heat elimina- 10 Plethysmograph experiment— quoted from Buxbaum— Lehrbuch der Hydrothera- pie, 1903. got TREATMENT OF FEVERS tion. The internal congestion is intense. Under these circum- stances the cold percussion or friction has a double effect. First, by the production of circulatory reaction the spasm of the peripheral vessels is relieved and the internal congestion gives way because of an equalization of the circulation. The chill is thus aborted. Second, the leucocytes are "mobilized" and phagocytosis encouraged. In malaria the leucocytes forsake the peripheral circulation and accumulate in the viscera, espe- cially the spleen. Experiments with the oncometer show that cold applications cause contraction of this organ. This action, together with the stimulation of the vasomotors of the peri- pheral vessels, serves to distribute and energize this vast army of phagocytes. Besides the mobilization of the phagocytes, visceral globular stasis of the red cells is prevented. It is believed by Bass and Johns that for malarial parasites to pass from red cell to red cell, these must be in actual contact with each other in order that the parasite escape the destructive action of the serum in which they can not live for even a few minutes. Their conclusion is this: " From our observations of malarial plasmodia growing in vitro, we believe that in vivo they can pass from cell to cell only when a cell is in direct con- tact with another cell containing a segmenting parasite, and then only when the opening for the exit of merozoites occurs oppo- site the cell to be infected." If this conclusion be true, such reinfection of red cells would be greatly favored by the globular stasis which occurs at the time of the chill. On the other hand, it would be very greatly hindered by an active visceral and peripheral circulation in which condition the majority of the young parasites would for a long time be exposed to the destructive action of the serum and would be readily phagocytized by the leucocytes. Hot applications, beginning just before the onset of the chill, would serve to dilate the peripheral vessels and so counteract the vasoconstriction for the time-being. But such intense and prolonged heat has no tendency to combat the cause, i. e., it does not produce mobilization of the leucocytes nor cause them to destroy the parasites. On the contrary it has the opposite MALARIA 203 effect, viz., the causation of an increase in the visceral stasis of leucocytes and red cells and a lessening of phagocytic activity. Where a patient reacts poorly, a reaction must be ' ' com- pelled " by the use of local hot applications simultaneously with the cold. This is for the purpose of producing a sensation of warmth, while the essential effect — a brisk activity of the blood- vessels— is secured by the cold application accompanied by fric- tion or percussion. The following suggestive program will be found useful. It must be varied according to the reactive ability of the patient. Begin the first treatment of the series about six hours before the expected paroxysm and follow it with other treatments about every two hours. These should be continued until the time for the chill is well past. The first treatment may consist of an enema followed by a hot foot bath and two fomentations to the abdomen of brief dura- tion. As soon as the second fomentation has been placed, begin with a cold mitten friction. This latter should be given with very cold water and vigorous friction. Dry the patient and let him rest for an hour or an hour and a quarter. Next admin- ister quickly alternate hot and cold to the spine, followed by an alternate hot and cold percussion douche to the spine, splenic and hepatic. areas, and the legs. If necessary the patient may stand in a tub of hot water during this treatment or, if there is still less reactive ability manifest, give a hot shower while the cold douche is being administered. Let the patient drink freely of water both before and after each treatment. The third treatment may consist of a cold shallow rubbing bath lasting four or five minutes and preceeded, if necessary, by a hot pail pour to the legs and lower spine only. Two attendants should be provided to administer the shallow bath. Succeeding treat- ments should be carried on along the same line. These may be the cold mitten friction with ice water, the wet sheet rub, the percussion douche, the salt glow with pail pour, etc. In conclusion we can not do better than quote the principles given by Buxbaum: — u ' The best water treatment for malaria consists in the employ - 11 Cohen's System of Physiologic Therapeutics, Vol. IX, p. 136. 804 TREATMENT OF FEVERS merit 6f a cold application, combined with powerful thermic stimulation. The form of the application is a matter of indif- ference. The most important requirement, however, is the production of a good reaction. When this fails to take place, success will be wanting. With the powerful stimulating pro- cedure, which may be chosen according to personal preference, a fan douche to the region of the spleen may serviceably be conjoined. The principal objects of the therapeutist's attention are the proper selection of the time, and the production of a good reaction . ' The shorter the interval between the procedure and the anticipated chill, the more certain the result. With regard to the procedures to be employed, they consist in cold vigorous shower baths, a cold rub in course sheets in combina- tion with sheet baths; cold sitz baths of ten minutes' duration; cold full baths; plunge baths and other suitable measures. The treatment should be continued until the constitution of the blood, the digestion, and circulation are restored to normal — briefly, until every sign of cachexia has disappeared. "According to Strasser, the effect of hydriatic procedures is to be attributed to the fact that shortly before the attack the infected erythrocytes disintegrate under the influence of the powerful stimulation of cold, so that the plasmodia thus set free are destroyed by the phagocytes." l2 MEASLES Measles is an acute, contagious, febrile disease characterized by a blotchy exanthem and accompanied by coryza. It is usually uneventful in its course and not accompanied by any great mortality. However, the patient may be made much more comfortable during the febrile period, and the vital resist- ance so sustained that there is less tendency to bronchopneu- monia. The eruption does not appear until the fourth day, so the treatment must be begun before a positive diagnosis can be made. Ls J lnt.eresting to note that Bass and Johns voice a similar theory for the action of me. as shown by the following quotation: "It is suggested that quinine has no de- Mr^i 1?' n * "P™ malarial plasmodia. its effect being possibly to render the red Acting the parasite more permeable to the all sufficient destructive in flu- rum. If this is true, quinine would affect only the parasites in the circula- segment" ^ lodged in caPillaries, which would not be reached by it until thev MEASLES 205 In this disease, as well as in scarlet fever, the first thing to be accomplished is the relieving- of the internal congestion occasioned by the infective process. If the case is untreated, the visceral congestion is considerably lessened on the appear- ance of the eruption. The old idea that measles is much more serious if the eruption " strikes in," or does not appear frankly, is not wholly without foundation. At the time the eruption makes its appearance the skin becomes markedly congested and this serves to, at least partially, relieve the visceral congestion. A treatment which. most efficiently relieves the internal con- gestion is also conducive to the speedy appearance of the rash. In our practice we have seen this best accomplished by means of some hot sweating treatment, either the hot pack or bath, accompanied by the drinking of some hot liquid. The head should be kept cold by compresses or ice bags. In some cases, where there is not much chilliness, sweating is very well accomplished by the use of the wet sheet pack, prolonged to the sweating stage. This draws the blood from the viscera and congests the skin. At the termination of such a treatment, the case, if one of measles, will show the characteristic dull red, blotchy eruption. Baruch recommends some form of cold treatment for the same purpose and as an antipyretic throughout the febrile period. He prefers the graduated bath, or a warm bath in which the patient sits while cold water is poured over the chest and shoulders. The full expansion of the lungs occasioned by such treatment aids in the prevention of bronchopneumonia. Be- cause of the irritability of the skin, it is not best to employ friction during the cold bath. Cold affusions to the head and back of the neck are useful in relieving stitpor, delirium, and other cerebral symptoms. We have found the wet sheet pack, frequently renewed by sprinkling cold water over it, an excel- lent means of reducing the temperature and, at the same time, it provides against chilliness, since between each renewal of the pack, it warms up and reaction is completed. This maybe repeated until the temperature has been reduced to 101° F., or even less. The evaporating stage of the pack sh6uld last for a greater length of time than the heating stage, so that the total effect will be that of heat abstraction. 206 TREATMENT OF FEVERS Bronchopneumonia. Capillary bronchitis is the most serious and fatal of the complications arising- during- the course of measles. In this disease there is a special tendency to conges- tion of the mucous membranes of the respiratory tract, as evi- denced by the coryza which invariably accompanies it. The condition of the lung's may prove to be of a tubercular nature; this is not an infrequent sequel and one accompanied by a high mortality. In the treatment of bronchopneumonia, complicat- ing measles, we employ the same methods used in the treat- ment of this disease when occurring: alone. The child should be placed, at intervals of about three hours, in a bath at 90° — 95°. When sufficiently warm, let the child sit upright and cold affusions be applied to the chest, shoulders, and back. The water for the affusion may be at a temperature of from 70° — 75°. This vigorous means provokes an unusually deep inspir- ation, which is followed for a considerable time, by slower res- pirations of greater depth. It facilitates the expulsion of mucus. Another treatment that has given excellent success is the cold compress applied to the chest. This should be wrung from very cold water, applied quickly over the entire upper chest, allowed to remain for a very short time, and then re- newed. This may be repeated from two to four times, the last compress used being allowed to remain for thirty to sixty minutes. The chest may be slapped in rapid succession with cold wet towels. This, of course, should not be done if the temperature is very high. In the latter case the evaporating wet sheet pack provides for the reduction of the fever and serves to stimulate respiration. Gaseous interchange and oxy- genation of the blood are greatly promoted, the circulation is increased, and the heart strengthened. Among other measures that may be used to good advantage are cold sponging, hot sponging, and the cold towel rub. SCARLET FEVER Scarlatina ns an acute, contagious fever characterized by a diffuse scarlet erythema and accompanied by sore throat or tonsillitis. It has a higher mortality than measles and is accom- SCARLET FEVER 207 panied by more serious complications. In scarlet fever, as in all other febrile diseases, the chief objects to be attained by treatment are the maintaining of the vital resistance, increas- ing phagocytosis in order to combat the infection, sustaining the heart and circulation, and controlling the nervous manifes- tations by tonic measures. Before the appearance of the erup- tion, scarlet fever should be treated in precisely the same man- ner as measles. Usually by the time the physician is called, the eruption has already begun to make its appearance and here, as in measles, we have foun'd the use of the initial hot bath or pack most effectual in promoting a decided and general erup- tion. As soon as its appearance, or other symptoms give evi- dence that the internal congestion has been materially relieved, some form of cold treatment should immediately follow. Be- cause of the soar throat and tonsillitis, it may be necessary to precede the general hot treatment by fomentations to the neck and upper chest. Cold compresses or ice bags should be applied to the head at the same time, and the treatment accom- panied by a hot foot bath or leg pack. These partial hot appli- cations in themselves may produce general perspiration, in which case, it is imnecessary to use other hot treatment. A full hot bath may be serviceable in place of the hot pack, and when the patient has become thoroughly warmed, the succeeding cold treatment may be applied by proper graduation of the bath. The temperature must not be reduced too far, since it is im- possible to employ friction on account of the rash. The wet sheet pack, kept at the evaporating stage and fre- quently renewed, is a very efficient means of reducing the tem- perature, energizing the nerves and circulation. After the eruption has once appeared there need be no fear of ' ' driving the rash in." However, it is necessary to produce a decided cutaneous reaction with every cold treatment used. The ex- treme cold bath is contraindicated. Affusions and ablutions, beginning with water at 90° gradually lowering the tempera- ture until water at 70° or 75° is used, are also useful in con- trolling the temperature and assisting the heart's action. It is necessary that the patient drink a considerable quantity of water to provide for thorough elimination, because of the 208 TREATMENT OF FEVERS tendency to renal congestion and nephritis. This latter con- dition is the most important complication of scarlet fever. Nephritis. Should this condition appear during the febrile period, it is not necessary to stop all cold treatments, but the temperature should be somewhat moderated and the time shortened. Short hot applications may be made so as to en- hance the reactive ability, and these immediately followed by such measures as cold affusions, cold sponging, wet sheet pack, or the graduated bath. In the case of the graduated bath, the initial heating may be accomplished by beginning the bath at 95°— 98°, raising the temperature a few degrees until the patient is well warmed, and then gradually cooling the bath to 80° or 85°. Chilliness should not result from any treatment, as this tends to increase the renal congestion. If the wet sheet pack is used, the sheet may be wrung from hot water and then maintained at the evaporating stage and renewed by sprinkling cold water over the sheet. During all this time, the drinking of large quantities of water should be encouraged. If the nephritis should make its first appearance after, or at the close of, the febrile period, it is perhaps best to employ the means commonly used in treating nephritis, that is, diaphoretic measures. The hot bath with ice to the head and heart, the hot blanket pack, or partial hot applications, such as the hot foot bath accompanied by fomentations to the spine, chest, or abdomen, are all useful in producing sweating. The hot air bath may be administered in bed according to the plan mentioned under acute nephritis. If the hot blanket pack is used, it may be very conveniently followed by the wet sheet pack, wrung from water at 75° and continued to the sweating stage. Reaction should ensue promptly. The child may be left in this pack an hour or two, or until the sheet is nearly dry. The cold towel rub and cold mitten friction may be used to promote circulatory reaction, providing desquamation has well begun. It is best not to employ the cold mitten friction, should the nephritis occur before the eruption subsides. Under these treatments, the albumen gradually lessens and casts disappear from the urine. Should there be edema about the feet and ankles, the alternate hot and cold foot or leg bath should be INFLUENZA 209 used and followed by centripetal massage. To aid desquama- tion and prevent spreading- of the contagion, the cold mitten friction or salt glow may be used to hasten the removal of the scales. Either treatment should be followed by an oil rub to prevent further rubbing off of the contagion-carrying epi- thelium. Endocarditis. Should this complication arise, all cold tub baths should be discontinued, also cold affusions. The patient must be kept at absolute rest, with the ice bag to the heart intermittently. After the eruption has disappeared, there is no measure equal to the cold mitten friction in assisting the circu- lation and relieving the heart. For further treatment, see endocarditis in rheumatic fever. LA GRIPPE— INFLUENZA The clinical condition in influenza is quite different from that of typhoid fever. In this disease, the fever is of the short, high type, with rapid pulse and high blood pressure. These are the manifestations that are found in young adults. With older persons, the disease is quite likely to be accompanied by considerable asthenia, the digestive system and the nervous system bearing the brunt of the infective process. With younger persons the respiratory tract is more likely to be affected . Since this is a short sthenic fever, the treatment employed will differ considerably from that used in typhoid fever. Aside from cold applications to the head, it is unnecessary to employ long cold treatments for the purpose of reducing the fever and all generalized cold applications are contraindicated. With an individual that has been previously strong and well and is in good flesh, it may be possible to treat the case from the start by vigorous cold applications with friction. This enhances the vital resistance, increases leucocytosis and so combats the in- fection in a very direct manner. With cases as they usually present themselves, we have ob- tained the best results by the use of an initial sweating treat- ment such, for example, as the hot leg bath accompanied by fomentations to the spine or to the chest and throat, with cold 14 HO TREATMENT OF FEVERS compresses to the head and neck. (Plate IX.} At the same time, the patient should drink several glasses of hot lemonade. Chilliness is soon overcome and the patient begins to perspire profusely. As soon as profuse perspiration is well established, the patient may be given a graduated shower beginning at about 110°, gradually increasing the temperature to the limit of toleration. While in the hot spray, the patient should wear a cold compress to the head. As soon as he is again well warmed, the temperature should very gradually be reduced to 90°. This abstracts much of the heat that has been communicated to the body by the sweating treatment. The patient should now be put to bed with hot- water bottles to the feet, and allowed to perspire gently for a number of hours. Great care must be taken that the patient is not overheated by the sweating treatment, since fainting is quite likely to result unless the cold compresses to the head and neck are fre- quently renewed. In some cases it is necessary that the patient be in a recumbent position while taking the treatment and, for this reason, the horizontal electric light cabinet is very service- able in securing free diaphoresis. The use of the upright cabinet at the onset of la grippe is almost certain to result in fainting. In case this sweating treatment has been carried out in the evening, on the following morning the patient should be treated by preliminary hot applications for the purpose of relieving, the aching of the back and limbs. This is best accomplished by the leg pack and large fomentations to the spine. They should not be continued long and should be followed immediately by a vigorous cold mitten friction. From this point on, it is best to treat the case as far as possible with tonic measures, such as the cold mitten friction, cold towel rub, or the hot and cold douche to the spine and legs, finishing with the alternating douche to the feet. The sweating treatment should not be repeated unless it seems quite necessary. Any plan of treatment may fail of its best results in case the bowel is not thoroughly unloaded at the beginning. This may be best accomplished by thorough enemata. Special complica- tions require attention outside of the general plan of treating PLATE IX. A sudorific treatment to be given at the onset of influenza. INFLUENZA 211 influenza. Bronchitis and cough, with pain in the chest, should be treated by large fomentations, followed by the heat- ing- chest pack. Pharyngitis or tonsillitis should be treated in the same manner, that is, with fomentations, and a cold heating compress applied between treatments. The nervous symptoms are best met by the ice cap, or cold compress to the head. The pain may be very materially relieved by the use of very hot fomentations. In all cases, however, the treatment should be concluded with a vigorous cold mitten friction. It is not designed that the cold frictions shall materially lower the tem- perature in and of themselves, that is, the fall in temperature does not result immediately after the application, but rather succeeds in a few hours. If the temperature is very high, it may be effectually combated by the use of the ice bag to the heart with ice applications to the head. Both should be con- tinued with but little interruption. The asthenic type of influenza, except in old people or chronic invalids, is not now as common as during the pandemic of 1889 and the years immediately following. In the event of severe asthenia the treatment is to be carried on along general lines with special reference to those measures which will sustain the heart and circulation. The treatment of respiratory or diges- tive complications demands special care and is to be carried on along lines- laid down elsewhere. CHAPTER XVIII INFLAMMATION AND ANTIPHLOGISTIC EFFECTS BEFORE considering: the conditions present in inflammations and their treatment, it will be well to understand the prin- ciples involved in the production of certain circulatory effects which are much used in the treatment of inflammations. We shall, therefore, first turn our attention to the methods and principles concerned in the production of depletion and fluxion. Depletion is the reduction of congestion in a gfiven part or organ. Derivation is depletion secured by the withdrawing of blood from an organ or part of the body by increasing the amount of blood in some other part. Practically, it is the reduction of congestion (and inflammation) by drawing the blood from the part congested into some other part. There is produced a col- lateral hyperemia with local anemia. Fluxion consists in increasing the rapidity of the blood cur- rent in a particular part, and consequently, the total amount of blood passing through that part in a given time. It is the production of arterial hyperemia. DEPLETION— DERIVATION There are three practical methods of securing depletion: first, by the application of heat alone; second, by the applica- tion of cold alone; and third, by the application of both heat and cold applied simultaneously. The accompanying outline shows in a condensed form the principal points of each method. (212) te K ? fc 3.2 III DEPLETION 213 Application Heat alone Cold alone Methods of Securing Depletion Where Placed Mode of Action Examples of Use Derivation Col late ral — o ve r part or at a dis- tance Proximal or di- rectly over part Heat and Cold over part cold sim- or proximal ultane- Heat collateral ously Direct or reflex Reflex Derivation Pleurisy Renal con- gestion Acute rheu- matism, in- fectious ar- thritis Acute appen- dicitis Acute salpin- g-itis Simultaneous Heat and Cold. Depletion is most effectually secured by the simultaneous application of both heat and cold in the following' manner {Plate X.): A large very hot applica- tion is made to a distant part; in many cases, it extends up to and includes the congested part. At the same time ah ice bag", ice pack, or ice compress is placed directly over the inflamed organ. In this way collateral hyperemia is secured and the local anemia reenforced by the direct or reflex vasoconstrict- ing influence of the ice. The local anemia is made extreme by both a " push " and a " pull " effect on the circulation, the " pull " being secured by the vis a fronte of the hot application, and the ' ' push ' ' by the vis a tergo of the reflex contraction of the blood-vessels, due to the cold application over the part. The most effective derivation is secured by direct contact of the body with hot water. A hot leg" bath is more effective than a hot leg pack, and a hot leg pack with* the wet blanket applied directly to the skin is more effective than where a dry blanket intervenes. Neither the local hot air bath or the local electric light bath (or either as a general application) are as effective as a hot pack or a local hot bath. The reason for this difference is found in the fact that the blood-vessels dilate to a much greater extent under the action of hot water applied directly to the skin surface. The hot air bath and the electric light bath may produce more profuse perspiration, but the blood- g!4 ANTIPHLOGISTIC EFFECTS vessels do not dilate to the same degree possible under the action of hot water. However, in the case of a very hot full tub bath and a hot blanket pack, the surface derivation is so extreme in the former case as to cause fainting: when it is first entered, with congestion of the brain later on because of the general rise in blood pressure. For this reason, the full tub bath for extreme derivation is not a practical application, and in practice we use the hot blanket pack with the continuous application of ice to the head and neck and also to the heart if necessary. The following are the principal derivative measures indicated in the acute stage of the diseases mentioned: — 1. APPENDICITIS. Hot hip and leg pack, with ice bag over the appendix. 2. PERITONITIS. Hot hip and leg pack, or leg pack only, with ice compress or ice bags to the abdomen. 3. PUERPERAL INFECTION AND ACUTE SALPINGITIS. Full hot blanket pack, or hip and leg pack, with ice to the pelvis. 4. ACUTE CONGESTION OF THE LUNGS. Hot leg bath, hip and leg pack, or full blanket pack, with or without cracked ice compress over the lobe affected. 5. MENINGITIS. Hot leg pack, with ice cravat, ice cap and ice bag to the base of the brain and the upper spine. 6. MASTOIDITIS. Hot leg bath with ice cravat or ice bag over carotid artery, ice cap, and fomentations to the mastoid. 7. ALVEOLAR ABSCESS. Same as above, except fomentations to the jaw. 8. ACUTE OSTEOMYELITIS (of tibia) . Fomentations to leg, or leg pack, with ice over the femoral artery. 9. CEREBRAL CONGESTION. Hot leg bath with ice cravat, ice cap, or cold compress to the entire face and cranium. 10. RENAL CONGESTION. Fomentations to back; hot trunk pack or full blanket pack, with ice bag over lower third of sternum. Precautions: In order to maintain collateral hyperemia, the treatment must be concluded with such a vigorous tonic meas- ure as a cold mitten friction applied to the part previously covered by the hot application. The hot application alone pro- DEPLETION 215 duces passive dilatation of the blood-vessels. If the treatment is stopped here, the circulation will soon equalize itself, or even a worse internal congestion may occur. The cold mitten fric- tion, however, produces an active dilatation (alternate dilata- tion and contraction) of the blood-vessels, thus maintaining- for a longer time the derivation secured by the hot. Depletion by Heat Alone. In some cases sufficient blood can be withdrawn from a part by applying heat over the cutaneous branches coming from the artery supplying the deeper con- gested part or organ. In this case the larger flow of blood is diverted into the cutaneous (and superficial) branches, leaving less to pass to the deeper branches. Examples of this are found in the treatment of, — 1. PLEURISY. Large fomentations to the chest divert the blood flowing in the intercostal and internal mammary arteries from the pleural branches to the posterior, lateral, and anterior cutaneous branches. 2 RENAL CONGESTION. Large fomentations over the lower dorsal and lumbar spine the entire width of the back. This diverts the blood from the renal arteries to the lower intercostal and lateral lumbar branches of the aorta. 3. SIMPLE SPINAL CONGESTION. Large fomentations to the spine divert the blood from the spinal arteries to the posterior cutaneous arteries supplying the skin and muscles of the back. 4. CONGESTIVE SCIATICA. Large fomentations to back and side of thigh divert the blood from the nerve to the skin. 5. TRIGEMINAL NEURALGIA. Fomentations to side of face divert the blood to the skin. This may be reenforced by the use of an ice bag over the carotid, thus mechanically lessening the total volume of blood going to the head. Precautions: In pleurisy and neuralgia, cold increases the pain, hence can not be used over the seat of the pain. Depletion by Cold Alone. In a few conditions a congestion or inflammation may be sufficiently reduced by the use of ice or other cold application applied directly over the part or over the artery supplying the part, without the addition of collateral heat. In acute articular rheumatism and other acute infectious arthritides this method is most effective, in fact in our experi- 216 ANTIPHLOGISTIC EFFECTS ence, almost specific. In some cases of brain congestion ice over the carotids and cold applications to the head and face are all that is needed. In the early stage a boil may be aborted by applying" an ice bag directly over the seat of the infection. FLUXION When hot and cold applications are used to secure depletion, they are used simultaneously and to different areas. If the hot and cold are used alternately and to the same area, the result is fluxion. This may be either by direct effect in the part treated, or by reflex action in a related part. This effect is intensified by friction or percussion. All alternate hot and cold applications are tonic, both locally and generally. We may here, for the sake of clearness and brevity, confine ourselves to the consideration of measures desired to produce chiefly violent circulatory reaction in a given part or organ. The following are the principal means used to produce fluxion: — 1. Alternate hot and cold, using fomentations and ice, or fomentations and cold compresses (revulsive compress). 2. Alternate hot and cold douches or sprays, as to spine, legs, liver, etc. 3. Alternate hot and cold packs. 4. Alternate hot and cold, as to head or kidneys and sternum. 5. Revulsive or alternate hot and cold sitz bath. 6. Alternate hot and cold foot or leg bath. 7. Alternate hot and cold immersion, as of hand and arm. 8. Alternate hot and cold vaginal douche, rectal irrigation, etc. In all the above measures, the condition prodiiced is that of active (arterial) hyperemia. The alternate dilatation and con- traction of the blood-vessels is stimulated. This condition is known as active dilatation. These alternating changes of vaso- constriction and vasodilatation are more rapid and extreme than the normal. They very markedly increase the number of white blood cells in a given part, and consequently the resulting phagocytosis. It is this which makes it especially valuable, and almost indispensable in some acute congestions and inflam- FLUXION 217 mations, such as an acute infection of a hand or a foot, where lymphangitis and lymphadenitis are likely to follow so quickly. Perhaps the largest field for the use of fluxion (arterial hyper- emia) is in chronic congestions, whether a sequel to chronic infections or non-inflammatory. In these cases the congestion is of a passive type, i. e., venous stasis. The treatment is also indicated in local anemias. Below are given some of the more important indications for the use of fluxion: — 1. Acute infections, as of hand, arm, or foot. 2. Convalescence from all local infections (stage of passive or venous congestion). 3. Chronic congestion of liver. 4. Chronic pelvic congestion, as of uterus or adnexa, whether simple or following infections. 5. Uterine subinvolution. 6. Amenorrhea, 7. Myelitis (chronic stage). 8. Locomotor ataxia and other paralyses of spinal origin (in chronic stage). 9. Alcoholic neuritis (after acute stage). 10. Muscular atrophies. 11. Tubercular arthritis and synovitis. 12. Chronic osteomyelitis. 13. Varicose ulcer. Precautions: In acute infections, massage effects, such as friction or percussion, should be avoided. Dire effects in the quick spread of the bacteria to other parts, will result if these are used. Revulsion. According to Borland, this term is synonomous with derivation and depletion. Kellogg evidently uses it to designate the mode of giving a hot and cold application, the chief effect of which is fluxion, for example, a revulsive com- press— a treatment consisting of a single prolonged hot appli- cation, followed by a single very brief application of cold. Again it is used to designate derivation secured by collateral fluxion, as in the use of the hot and cold foot or leg bath, or a 218 ANTIPHLOGISTIC EFFECTS hot and cold percussion douche to the feet and leg's to relieve cerebral congestion. When hot and cold are alternately applied to one part of the body, thus producing- fluxion in that part, it will withdraw more or less blood from other related or distant parts. This diverse application of the term has led to no little confusion. While the term can not be fully dispensed with, the student should bear in mind that the effect is that of. either derivation or fluxion. PATHOGENESIS OF INFLAMMATION Inflammation consists of the series of changes constituting: the local manifestation of the attempt at repair of actual or referred injury to a part, or briefly, it is the local attempt A B Fig. 50. A— arterioles and capillaries, normal, B— the same after introduction of an irritant foreign body and the beginning of inflam- mation. at repair of actual or referred injury. Inflammation is the reaction of irritated and damaged tissues which still retain vitality." ] The pathologic conditions in an inflammatory process may be partially understood by the five cardinal symptoms, viz., — 1. Rubor — redness. 2. Tumor — swelling. 3. Calor — heat. 4. Dolor — pain. 5. Functio laesa — loss of function. The primary cause of the inflammation, whatever it may be, is responsible for these conditions, which are largely circula- tory disturbances. The condition in the acute stage is one of (1) arterial hyperemia {Fig. 50.} with (2) a serous exudate, 1 Adami— Inflammation, pp. 5. 227. PRINCIPLES OF TREATMENT 219 and (3) an increasing number of leucocytes in the blood stream and tissues; from the latter, they return to the blood stream less rapidly than normal. (4) The inflamed part is bright red. (5) The pain is severe and * of ten throbbing- in character because of the increasing tension on the nerves caused by the swelling.1' In the chronic stage, the condition is one of (l) venous con- gestion (passive hyperemia). (2) There is a beginning organ- ization of the exudate, and (3) a dearth of leucocytes. (4) The part is of a dark red or bluish color. (5) The pain is less severe, and described as dull and heavy in character. In the intermediate stages, the inflammatory process passes gradually from the first to the last condition. The circulation begins to be slowed, and more and more blood accumulates in the capil- laries and veins, less arterial blood being present, so that the total amount of blood in the organ is increased above normal. The severe or throbbing pain gives way to the more constant, but less severe, dull pain. The leucocytes find their way back into the circulation (lymphatic or blood) if no suppuration occurs, and the number in the tissue decreases. PRINCIPLES OF TREATMENT In the Acute Stage. (l) Limit the congestion, (2) hasten the absorption of the exudate and prevent further exudation, (3) energize and assist the phagocytes in combating the infec- tion or noxious agent, (4) relieve the pain. While inflamma- tion is a protective process, it must not be supposed that it is always well regulated, or able, unassisted, to cope with the disturbing cause. The serous exudate of this stage consists of a more concen- trate lymph than normal, z. \vs that extreme cold treatment so greatly enhances oxidation as to quickly change the aspect of combustion from support by car- bohydrates to support by fat. These experiments were done with normal individuals. From this report10 we quote the fol- lowing:— During the shivering which followed the second cold bath the metabolism, as measured by the heat production, was 63 per cent higher than during the subsequent resting period, but the respiratory quotient of 0.75 remained unchanged during both periods. It is evident from this experiment that the influ- ence of two successive cold baths, ivhich cause shivering during a period when the intestine is free from carbohydrate, is sufficient to change the metabolism from one maintained at the expense of carbo- hydrate (R. Q.=0.99) to one maintained essentially by the combus- tion of fat (R. Q.=0.75}. Hence the organism of man may be quickly rid of glycogen by shivering. 10 The Influence of Cold Baths on the Glycogen Content of Man. American Journal of Physiology, Vol. XXVII. No. V, p. 427. DIABETES 281 ' The greatest increase in heat production, which was brought about by the cold baths, was 181 per cent above the normal. The urine remained free from albumen and from sugar. ' ' In connection with the oxidation of sugar, it is interesting to note the results obtained by two French observers " from the inhalation of ozone in patients suffering from glycosuria: — Labbe and Perochon have their patients with glycosuria inhale ozone for from fifteen to thirty minutes a day, and have found that in some way it promotes the utilization of sugar, so that sugar disappears more or less completely from the urine. Eight typical cases are described to show the benefit thus realized. In one case, for example, a man of 57 had had diabetes for six years, and 50 gm. of sugar were found in the liter of urine. He inhaled ozone for fifteen minutes a day for two months, by the end of which time the sugar had vanished from his urine. Two weeks later the sugar appeared anew in the urine and ran up to 8 gm., but subsided to traces on resumption of the ozone treatment. Another patient was a woman of 66 with diabetes for many years. She had 150 or 200 gm. of sugar to the liter of urine, and this became materially reduced under the ozone treatment and her severe pruritus be- came very much improved." 12 In the practical application of hydrotherapy the treatment must bs carefully graduated and mild tonics used at first, because of the lowered vitality of almost all diabetics. Local hot applications followed by the wet hand rub or cold mitten friction may be used to begin with, also the neutral faradic tub, graduated shower, and cool affusions. After becoming accus- tomed to these treatments the patient may, if in good flesh, be given a wet sheet rub, dripping sheet rub, cold shallow bath, and alternate douches. In some cases the cold plunge may even be ventured upon. As rapidly as able, the patient should be encouraged to take moderate exercise in the open air; the effect is greater if the air is cold. These measures improve the appetite and stimulate digestion and assimilation. The feeling 11 Labbe and Perochon — Ozone in the Treatment of Glycosuria, Presse Medicale, March 19, XXI, No. 23. 12 Abstract in Journal of American Medical Association, April 26, 1913. 282 STIMULANTS AND TONICS of languor and debility gives way to a greater inclination to exercise, and so hydrotherapy indirectly makes possible the use of the other great aid in oxidation — bodily activity. With thin diabetics, the prognosis is less favorable. They can take only the milder tonic treatments. Neither do they bear well any great reduction in the diet. But even with such unfavorable conditions, astonishingly good results may be obtained by carefully graded hydrotherapy combined with light massage. Much time should be spent in the open air and sun- shine, careful attention being paid to general hygiene and especially to good skin activity. CEREBRAL CONGESTION Due to the Effects of Sunstroke or Heatstroke Patients who have once suffered from sunstroke must select a cold climate in which to live. Even moderate heat for any length of time produces harmful results. It would seem that in this condition the vasomotor centers have been so interfered with that there is a loss of vascular control. This may, in some cases, be so extreme that even a short hot treatment limited to a small area may induce general vaso-dilatation with a special tendency toward cerebral congestion. The condition is best treated by cold applications accompanied by friction. No hot applications at all should be used. During all treatment, the head should be kept cool by cold compresses and the ice bag, or the ice cravat to the neck. The cold mitten friction, cold towel rub, wet sheet rub, cool or cold showers and sprays may all be used according as the conditions indicate. If the brain seems unduly congested a great deal of the time, deriva- tion is best secured by the cold percussion douche to the feet. Much the same line of treatment is to be pursued in chronic •nitroglycerine poisoning, which occasionally occurs in miners. This may be very troublesome. It is accompanied by severe headaches, in some cases assuming a migraine type. In treat- ing these patients, the cerebral circulation should be steadied by bathing the head in cold water before other treatment is be- gun, which latter should consist of cold showers, cold percus- VALVULAR HEART DISEASE 283 sion douches, and the cold plunge. If milder measures must be used, the cold mitten friction with ice water gives excellent results. However, these patients bear much more extreme cold treatment than any other class, and seem to have no diffi- culty in reacting. VALVULAR HEART DISEASE Etiology and Pathology Organic heart disease refers to such diseases of the heart as are due to gross structural changes. The term is applied almost exclusively to chronic valvular disease. In the larger number of cases this is the result of some acute inflammatory condition on or about the valves. These valve inflammations may arise as complications of rheumatic fever, tonsillitis, scarlet fever, sepsis, gonorrhoea, pneumonia, pleurisy, or pulmonary tuberculosis. Predispositions are found in pro- longed and heavy muscular exercise, auto-intoxication, gout, alcoholism, syphilis, Bright's disease, and arterio-sclerosis. The result is a valve orifice either too large or too small. Scar tissue following the inflammation may cause the valve segments to adhere to each other and so, by partially obstructing the orifice, cause stenosis; the valve leaflets may be partially de- stroyed or their attachments weakened so that the orifice is too large, or the heart dilated so that the segments are incom- petent to close the opening. In the first case, that is, stenosis, too little blood passes through the orifice and extra force is required to overcome the obstruction. In the latter case, part of the blood returns through the enlarged opening or past the incompetent valves, so that regurgitation takes place at every heart beat. Because of the former condition, the first change in the heart muscle is that of hypertrophy. In the second condition, the first change is that of dilatation of one or more cardiac chambers. If com- pensated, both conditions result in great hypertrophy and thickening of the muscular wall. The maximum force of the heart will be greater than normal, but the work required of it is also greater, so that in this condition, its reserve force above what it ordinarily uses is less than the normal reserve. Here 284 STIMULANTS AND TONICS the heart is said to be in a state of compensation, since the muscle is so much hypertrophied as to still be able to perform its work under ordinary circumstances. Sometimes there is little or no such reserve, i. e., the heart may have barely enough force for its work when the body is at rest. In this eo- = . -- 0 IS — i i i i ' / / •• / i / / _ i / t / / 10 = RS i - / / / / * Q X / 8 — HI y / 7 f s -1 I C OMPENSAT S\\\N\\\\\\ PENSAT&O / / / / / 1 / / 4 oc- rj -< - — (} — ^ — g- o y Z o 3 — z /, 3 u / --D s 2 — »— 1 / ^ H 1=1 • o N •0 ra Fig. 54. Diagram showing dynamic conditions in valvular heart disease: A— force required at rest under conditions indicated, B — additional force demanded by moderate muscular work" C — reserve cardiac force above that needed for moderate work. condition, the heart is said to be in a state of broken compensa- tion. This state, that is, where the maximum force is in con- stant use, is revealed by such symptoms as edema, cyanosis, dyspnoea, heart pang or distress, rapid pulse, palpitation, sleep start, enlarged liver, etc. Moderate muscular work demands four times the energy used at rest, and the total reserve power of the heart muscle is from VALVULAR HEART DISEASE 285 eleven to thirteen times the normal output during rest.13 This proportion is shown in Fig. 54 1. In the case of valvular lesions so bad as to require three or four times the usual expenditure of energy, it will be seen that only during complete physical rest will the heart be able to accomplish its work (Fig-. 54 //.). Moderate muscular exercise will demand more energy than it possesses, and so will be accompanied by signs of broken com- pensation. In order that compensation may be restored, the muscular wall must nearly double its thickness to possess even a little reserve force, as shown in Fig. 54 III. Treatment It will be readily seen that the above conditions set forth two indications for treatment: First, so shaping conditions that the heart may be given opportunity to increase its muscular tissue and thereby its reserve force; second, as much as possible, re- lieve the heart of part of its work, not only temporarily in order to bring about the condition just mentioned, but also to con- stantly assist the overtaxed organ. These indications are met in the following procedures: — 1. Rest — Physical and Mental. This is first and foremost in importance. It is necessary . that absolute physical rest be observed in the state of broken compensation. Exercise should not be permitted until the heart has acquired at least some reserve force. According to the gravity of the case, physical rest may be secured by absolute quiet in bed, by rest in a wheel chair with an attendant, or by restricted exercise. While at rest the body tissues demand less oxygen, and consequently less rapid circulation. It is quite as essential to eliminate all nerve strain, such as worry, apprehension, business or social cares, etc. Through the avenue of the sympathetic system, these irritate and overstimulate the intrinsic nerves of the heart muscle. 2 . The Ice Bag to the Heart. This is one of the most effi- cient means we possess in its ability to produce direct tonic effects upon the heart muscle. Prolonged, continued cold lessens the rate and increases the length of the period of rest 13 Hutchison Applied Physiology, p. 116. 286 STIMULANTS AND TONICS (diastole). It also shortens the systole and increases its force. The ice bag- should be well wrapped to modify the intensity, so that the application may be prolonged. In some cases, the cold compress is to be preferred. While the ice bag tends to increase the force of the systole, it can hardly be said to come under the head of pure stimulants, since by its repeated use, the effects of over-stfmulation are never seen. It always exercises a bene- ficial effect in aiding hypertrophy of the heart muscle, since by its shortening the systole and increasing the length of the dias- tole, the actual period of rest is increased. It may, therefore, be said to be a true physiologic measure. 3. Measures which Stimulate the Peripheral Heart, perform- ing part of the work of the circulation, increasing its activity, and so aiding the central heart. In the chapter on the peri- pheral heart, we have discussed at length the physiology of the blood-vessels, their normal action, and the rationale of the measures used to increase this activity. We need here only briefly summarize the facts already pointed out. Independently of the heart, the blood-vessels exert a pumping or propulsive action upon the blood stream. Lauder Brunton w makes the following observation relative to this activity: " When working under Professor Ludwig in 1869, he directed my attention to the contractile power of the small arteries apart from any nerve center, and while watching their movements I have sometimes seen a regular peristaltic action take place, by which the blood was driven forward in the arteriole just as faecal matter would be driven forward in the intestine." Franke discusses the various theories prevailing in regard to the functional importance of the peripheral blood-vessels. His conclusions reaffirm, he asserts,' that the peripheral vessels have an independent pressure and suction action similar to that 'of the heart. This assumption is sustained by their anatomic structure, physiologic experiments, direct observation of the blood-vessels in living animals, and in certain pathologic con- ditions in man. At the points where there is the greatest resistance to the circulation, Nature has placed a system of 14 Therapeutics of the Circulation, p. 5. VALVULAR HEART DISEASE 287 especially powerful blood-vessels like a second peripheral heart, as in the portal and intestinal vessels. Compensation may fail from disturbances in the peripheral vessels as well as in the heart itself, and the peripheral system may compensate the heart at need; the vessels in the abdomen especially are the last resort of all means to maintain the balance of the circula- tion. These views, he considers, explain the beneficial effects of gymnastics, massage, and baths." 15 In disease, as long- as there remains any vasomotor control at all , the activity of the blood-vessels may be stimulated by applications to the skin surface. The condition of the blood- vessels to be sought in the treatment of valvular heart disease is that known as active dilatation, not only of the arterioles, but also of the other blood-vessels. It consists of an alternate contraction and relaxation occurring at regular intervals. It is, in short, a pumping action. It is often astonishing to note the amount of assistance rendered the circulation in this way, as shown by prompt decrease in the pulse rate following, or even during, some of the procedures listed below. These may be given separately, combined in one treatment or at different times during a course of treatment, as indicated by conditions in the individual case. (a) Massage. Friction is perhaps the mildest of measures by which the peripheral circulation may be stimulated. It stimu- lates the arterioles and, by proper movements, the venous cir- culation is hastened. All the other procedures of massage are also vasomotor excitants. The procedure of deep kneading accomplishes more than the other movements of massage. It acts upon the circulation in almost the same manner as exercise. The alternate compres- sion and release of the muscles forces on their contained blood, so that the rate of flow is greatly accelerated. Lauder Brunton records 16 graphically the results of some interesting experiments showing the increase in the rate of venous outflow from muscles during and after massage. In some instances the rapidity was increased two or three times the normal rate. 15 Abstract in Journal of American Medical Association of article by M. Franke in Wiener klinische Wochenschrift, March 10, 1910, XXIII, No. 10, p. 047. 16 Therapeutics of the Circulation, p. 135. 288 STIMULANTS AND TONICS Mechanical vibration is quite similar in its effect to manual massage. Vibration, when properly given, is an excellent means of assisting the peripheral circulation, especially that of the feet and limbs. Vibration may also be given to the back and other parts, as indicated. (b) Hydriatic Vasomotor Tonics. The cold mitten friction has the greatest range of adaptability in organic heart disease. It can be used in all stages from the inception of the acute endocarditis through all the varying conditions of established or broken compensation. This is largely due to the readiness with which it may be made a mild, medium, or powerful vaso- motor tonic and stimulant. This can be accomplished by vary- ing the temperature of the water used and altering the amount and vigorousness of the friction given. We have never observed, even after the most vigorous cold mitten friction, or its long use over a period of months, any overstimulation such as does sometimes occur with the effervescent bath. The cold mitten friction and ice bag can be used in the acute stage of endocardial inflammation, while it might be dangerous to use the Nauheim bath in this stage. There are many other hydri- atic measures similar in effect to the cold mitten friction. Each has its advantages and special indications, as well as limitations. The following is a list of the more important and commonly used hydriatic measures in the treatment of organic heart disease: The salt glow; hot and cold to the spine; hot and cold douche to the spine, legs, and feet; the alternate hot and cold foot or leg bath. Brief fomentations followed by a brisk but brief cold mitten friction may be given to any part of the body as a means of stimulating the peripheral circulation. (c) Nauheim or Effervescent Bath. The essential feature here is the chemical irritation of the skin produced by the carbon dioxide and salines with which the water is charged. Natural carbonated waters can be secured in only a few locali- ties, but the carbonic acid gas may be produced artificially in any one of several ways. It powerfully stimulates the vaso- motors, having, however, a cumulative action on the vaso- dilators 17 so that the heart is left without a resistance governor. 17 Hare— Practical Therapeutics. VALVULAR HEART DISEASE 289 For this reason it is necessary to discontinue the treatment at intervals in order to obviate palpitation and other disturbing- symptoms. The cutaneous irritation also reflexly stimulates the heart (Hare). This may be another factor in the produc- tion of palpitation by over-stimulation. The cooler the water the less likely its occurrence. When the patient first begins to take the Nauheim bath, it should not be continued longer than about eight minutes at a temperature of 95° F. Five minutes may be better in some cases. An ice bag or cold coil should be placed over the heart. The bath may be repeated two or three times a week for from two to four weeks. It is usually best to give a course of about twelve treatments, when two or three weeks should be omitted. In each succeeding treatment the temperature of the water may be slightly lowered until the bath is taken in water even as low as 80°. The duration of the bath may be increased up to twelve, or under exceptional circumstances, fifteen minutes. The longer the duration of each bath and the more frequent its repetition, the greater is the liability to over-stimulation. This is evidenced by palpitation, tachycardia, cyanosis, and dyspnoea. When carefully given, the Nauheim bath is one of the most useful of vasomotor stimulants and tonics; certainly it is the most powerful . In a single treatment administered to a patient with a dilated heart, the area of cardiac dullness may be reduced in diameter by as much as three-quarters of an inch or even a little over an inch. These results are not occasional, but are the general rule. The ice bag is very useful in maintaining this effect. A very large cardiac liver may be reduced to normal by a course of such treatment combined with other physiologic vasomotor tonics. These results are graphically shown in the accompanying physical chart (Fig. 55.).. (d) Resistant Gymnastics. This system is known as the Schott treatment. As carried out by the Schott Brothers, it is combined with the Nauheim bath. It consists of a series or system of graduated exercises. At first the patient is assisted by the attendant; later, with apparatus or alone. First one group of muscles is exercised and then another, until the prin- cipal muscle groups of the body have been gone over. For 19 290 STIMULANTS AND TONICS example, while the attendant resists, the patient gradually con- tracts the biceps, flexing- the forearm. When the forearm has been flexed, the patient contracts the extensors while the attendant resists the movement. This 'is gone through with a number of times for each group of muscles. With each suc- ceeding- treatment the number of movements and the strength Fig. 55. A— border of cardiac dullness in a case of di- lated heart, B — same after a single Nauheim bath, C — lower edge of congested (cardiac) liver, D — same after a course of tonic hydrotherapy. of the resistance is increased.'8 The gradual contraction and relaxation of first one and then another group of muscles hastens the peripheral circulation and tends to induce the state of active dilatation of the blood-vessels. This treatment should not be applied in acute endocarditis, but is applicable in the chronic stage where compensation is not seriously broken. 18 For details see McKenzie— Exercise in Education and Medicine, p. 328. VALVULAR HEART DISEASE 291 O) Oertel Method. General exercises, such as walking-, use of the arms, etc., follow as a natural consequence of the method just described. As a system, the Oertel method consists in graduated climbing- exercises, up hills of various grades and finally even mountain climbing-. At first, the patient walks for short distances each day; and later, longer distances and up steeper grades. This is, of course, applicable only where a fair degree of compensation has already been established; never when the compensation is broken or in the slightest impaired. Where systematically followed for months or years, it has resulted in much good and will secure for the patient the maxi- mum cardiac reserve. These measures combined with careful diet regulation, fresh air, and sunshine will give results which often appear like a complete cure, but of course, do not remove the defect in the heart. At the beginning of the incompetency, the progress may be stayed for years. The promptness with which these measures act and their efficiency has to be seen to obtain a real appreciation of their value. For example, the ice bag to the heart, accompanied by a cold mitten friction, may reduce the pulse from 115 or 120 per minute to 100 or less within fifteen or twenty minutes. In case of a dilated heart, the cardiac dull- ness may decrease more than an inch in diameter and the apex retract half an inch or more toward its normal position follow- ing a single treatment. In case the valve is relatively insuffi- cient, the murmur occasioned by this insufficiency may entirely disappear, whereas before treatment, it may have been con- sidered to constitute a real organic lesion. The minor mur- murs of the valves secondarily affected often disappear following a treatment of fifteen minutes with the ice bag to the heart and the cold mitten friction, or ten minutes in a Nauheim bath. Contraindications. Extreme stimulants and excitants are contraindicated in organic heart disease, unless it may be in emergency. For this reason, the percussion douche to the chest, wet sheet rub, the cold plunge, and such measures should not be used. The use of electricity in any form may produce shock. The electric light bath is usually contraindicated or, if used at all, it must be in those patients which have acquired 292 STIMULANTS AND TONICS a good degree of compensation, and then only for a short time. All other extreme sudorific measures are contraindicated. General Program We have already outlined under the head of endocarditis the treatment for the stage of acute inflammation. As soon as the endocardial inflammation subsides, the patient may be given daily or three times a week a light general massage, avoid- ing the chest. The ice bag should be applied to the heart four or five different times during the day, being kept in place from twenty to thirty minutes each time. Once daily the patient should have a treatment consisting of a combination of some of the following measures: Hot foot bath, fomentations to the abdomen, hot and cold to the spine, cold mitten friction, and cold towel rub. This tonic treatment is best given during the forenoon. The massage may be reserved for the afternoon or evening. If there is much restlessness or insomnia, it may be best to give a hot and cold foot bath just before retiring. Dur- ing this time the patient should be kept in bed; but when the pulse has become normal, he may change to the wheel chair, and later, be allowed about the room, walking a few steps or for short distances only. The pulse should become normal be- fore any regular walking exercises are taken. The patient may now be given a salt glow, alternate douche to the feet and legs, graduated shower, etc. The Nauheim bath may be given after the temperature has been normal for a month or two. This should be followed by the Schott treatment, which at first should last only a few minutes and consist of mild exercises. Later this may be prolonged and increased in severity. In case the patient comes under observation during the chronic stage, with compensation broken, the treatment maybe begun at this point or perhaps with milder measures. The resistant movements should not, however, be used during the stage of broken compensation. Care must be taken that the patient is not treated too frequently. This may often seem necessary, but it will be found better to allow the patient suffi- cient time for rest. Three treatments a day are usually ample and only one of these should consist of the more vigorous VALVULAR HEART DISEASE 293 stimulating- measures. The evening treatment should be mild in character, sedative, and conducive to sleep. The afternoon treatment may be the hot and cold foot bath followed by mas- sage. This at first should be mild and not last more than fifteen or twenty minutes. Complications Edema. The edema of the feet and legs accompanying- car- diac disease will improve as compensation is restored, so that all of the measures recommended during the stag-e of broken compensation will aid in the reducing of the dropsy. The local measure which we have found most useful is the alternate hot and cold leg- bath. The water should come sufficiently high to more than cover the edematous part. The limbs should be immersed in hot water for one and a half to two minutes and then in the cold for ten to fifteen seconds. It is best to make the hot water as hot as can be borne, gradually adding- more hot water as the toleration increases. The cold water may, at first, be used at a temperature of 50° — 70° F. Later, chunks of ice should be put into the receptacle for the cold water. From five to ten changes may be made at one treatment. The limbs should be dried from the cold water, and the drying fol- lowed by massage consisting principally of centripetal move- ments. The limbs should be kept elevated until the edema has nearly all subsided. In the minor grades of edema, that is, where there is swell- ing only about the ankles, vibration may be applied to the feet by means of the vibrating foot machine. The hot and cold leg bath, together with massage, should be repeated daily. Congestion of Liver. The liver may remain congested for some time after the heart condition has materially improved. Because of the nature of the hepatic tissue, the organ tends to remain enlarged. The passive congestion does not readily re- spond to treatment. In spite of these facts, an enormously enlarged liver may be caused to return to nearly normal size by a month or two of vigorous treatment. The patient should be given large fomentations over the liver. It will be found help- ful to place an ice bag under the center of the fomentation. 294 STIMULANTS AND TONICS The ice, having- a greater reflex effect, tends to contract the blood-vessels of the liver, while the hot application shows its effect chiefly in derivation. Alternating- with this treatment, the revulsive compress or hot and cold to the liver should be used. The alternate douche to the hepatic region is one of the best measures that can be used. While acting somewhat indi- rectly by a derivative process, the hot and cold leg bath will be found to be as efficient as the local treatment. Acute Edema of the Lungs. This condition may come on be- cause of chilling- and nervous shock. The heart becomes en- gorged and the chambers dilated at the same time. The patient should be immediately wrapped in a large blanket, the feet and legs being placed in hot water and an ice bag held against the precordia. It is usually necessary for the patient to sit up. The ice bag may be removed every three or four minutes, the skin being- warmed by brisk rubbing. Another attendant should apply to the spine a large fomentation, so as to cover its entire length and breadth. When the skin is well redderfed, a brief but very cold and brisk cold mitten friction should follow. Another fomentation should be applied to the spine, or the part may be dried well and covered with the blanket. Each arm and leg should be treated in a similar manner, that is, the skin well warmed and reddened by a fomentation and immedi- ately followed by a cold mitten friction. Each part should be thoroughly dried with a rough towel, and the drying followed by friction with the bare hand until the part is again warm and red. The object to be obtained in this treatment is the drawing of the blood from the heart and lungs to the skin and skeletal muscles. However, this can not be effectually done by hot alone, but must be accomplished by what may be termed " col- lateral fluxion," that is, the blood-vessels of the surface must be stimulated to unusual activity, so that the blood will be held in the periphery. This not only acts powerfully, but leaves no bad after effects such as are frequently noticed when these com- plications are treated by digitalis, nitroglycerine, and strych- nine. Neither are these latter stimulants able to accomplish the desired result in extreme cases. In a few hours the moist rales in the chest, which can at first be heard at some distance, OBESITY WITH FA TTY HE A R T 295 will have entirely disappeared. The finer crepitant rales which remain in the bases of the lower lobes should clear up in from one to three days. Palpitation and Arrhythmia. These conditions are largely due to digestive disturbances, especially that form of indiges- tion accompanied by gas formation. The treatment should, therefore, be directed toward the relieving of constipation and decreasing of amylaceous dyspepsia. It may be necessary to avoid even moderate quantities of starchy foods unless most thoroughly dextrinized. Tachycardia is best controlled by the ice bag, cold mitten friction, rest, etc. Nervous disturbances, nerve fatigue, etc., are also responsible for temporary arrhy- thmia. OBESITY WITH FATTY HEART It is not safe to employ extreme sweating measures in obesity accompanied by fatty degeneration of the heart muscle. Con- sequently, the treatment of these cases at the hot springs is a dangerous procedure. They must be treated in much the same manner as valvular heart disease. The patient should be kept at rest with an ice bag over the heart for a considerable portion of the time. Beside this, the patient should be given cold mitten frictions, cold towel rubs, hot and cold to the spine, general massage; and later, the alternate douche to the spine and legs, hot and cold foot bath, wet sheet rub, etc. Treat- ment should be very carefully graduated so that the heart is not subjected to over-stimulation before it has sufficiently in- creased its strength. EXCITANT AND STIMULATING EFFECTS In many emergencies it is necessary to employ extreme stimulating measures. These aim at the sustaining of vital activity in order to tide the system over a crisis, or until such time as the natural vitality of the patient comes to his assist- ance. Such measures are especially directed toward the heart, blood-vessels, and respiration. In collapse, surgical shock, drowning, and asphyxia, these measures are indicated. As we have noted many times, the greatest amount of assistance to 296 STIMULANTS AND TONICS 'the heart can be given by vigorous stimulation of the peri- pheral blood-vessels. In addition to such measures, certain applications may be used which have a direct reflex effect upon the heart itself. The most efficient reflex stimulation comes through the accelerator nerves. Short very hot fomentations may be applied to the front of the chest, covering well the heart area. This should be continued from thirty seconds to a minute, and immediately followed by the rubbing of a cake of ice over the heart. The extreme change in temperature pro- duces powerful stimulation. The part should be immediately dried, after which a second fomentation, very hot and con- tinued for half a minute or more may be used, again followed by the ice rub. After three or four such applications, it is well to rub vigorously with the bare hand the skin of the pre- cordia. These procedures may be given at the same time as artificial respiration. A very efficient stimulating measure is the slapping of the chest with a cold wet towel. If this is done during the move- ments of artificial respiration, it should be given while the inspiratory movement is made. In the asphyxia of the new- born infant, thermic applications are indispensable. If slap- ping of the chest and buttocks does not produce respiration, it is well to employ the alternate hot and cold immersion. Two large dishpans will be found handy containers for the hot water and the cold water. The hot water must not be hot enough to produce a burn or even erythema. It must be of such a tem- perature as may be well borne on the back of the hand or the cheek. The cold water should produce decided excitation, but ice water should not be used. The child should be held in the hot water for ten or fifteen seconds, and then merely dipped in the cold water. It should then be returned to the hot for about the same length of time and again dipped in the cold. Another plan which has proven equally effective is rubbing the chest with a smooth cake of ice while the infant lies in the hot water. These procedures are usually the most effective stimulants that can be used. All other means of resuscitating the new-born have their place and applicability. The physician should not too readily become discouraged in working with an asphyxiated UTERINE STIMULANTS 297 infant. It may require half or three-quarters of an hour to so stimulate the heart and respiration that the child will continue to breathe without artificial means. Uterine Stimulants Uterine excitation may be necessary in order to produce two different classes of effects, viz., contraction of the uterine muscle and prodiiction or increase of menstrual flow. Oxytocic Effects. In cases of inertia uteri, much may be accomplished without the use of forceps. That vvhich has given us the best results, producing- the most powerful contractions, has been the use of the ice bag- or cold compress to the lower abdomen, applied intermittently, especially just at the begin- ning- of the pain, or short intermittent applications of cold to the breasts. Alternate hot and cold applications may also be made to the lower abdomen. Both areas are in direct reflex connection with the uterus and produce powerful uterine con- tractions. These measures are less disagreeable to the patient than manual stimulation through the abdominal wall, and, on account of the tenderness often produced by this method, are to be preferred when they produce the desired result. Emmen&gogic Effects . Wherever amenorrhoea is due to pelvic anemia, it is necessary to supplement the general tonic treat- ment by special stimulating- treatments directed toward the pelvic org-ans. This may be accomplished by the cold percus-- sion douche to the lumbar and sacral regions, or the cold douche to the lumbar spine and feet. Hot vaginal irrigation is applicable in all cases. In some cases, alternate hot and cold vaginal irrigation may be used. The revulsive sitz is applicable in cases of extreme pelvic anemia. It may be fol- lowed by the cold lumbar and sacral douche. This douche should be accompanied by considerable percussion and given for only a short time. Vesical Stimulants Nearly all sudden thermic applications to the feet, leg's, or trunk produce contractions of the dedrusor muscle. This is especially true of the cold percussion douche to the feet, or the 298 STIMULANTS AND TONICS alternate hot and cold douche to the feet. The same result may be accomplished by the sudden application of the ice com- press to the lower abdomen or upper inner surfaces of the thighs. Intestinal Stimulants Intestinal excitation is indicated chiefly in constipation. There are a large "number of measures which are useful in re- laxed conditions of the intestinal musculature. The patient should be put upon some regular program. This may con- veniently embody several of the measures which are efficient in stimulating peristalsis. Among these measures are the hot enema, cold enema, or alternate hot and cold rectal irrigation. The graduated enema is an excellent means of accustoming the patient to the cold enema. It is especially useful in treating patients who have acquired the enema habit. Of external applications there may be employed fomentations to the abdo- men, the revulsive compress, hot and cold spray doiiche to the abdomen. These same measures may be applied to the spine from the middle of the dorsal region to the sacral region . The alternate hot and cold percussion douche to the feet and legs also tends to stimulate peristalsis. In atonic constipation the cold rubbing sitz is an excellent measure. It should last from two to four minutes and be followed by the alternate douche to the spine and abdomen. These measures should be carefully selected and utilized according to the severity of the case, special attention being given to the cause. The above treat- ments, except the hot enema and fomentations to the abdomen, are not applicable in spastic constipation such as that accom- panying lead poisoning. In this case it is best to use fomenta- tions to the abdomen, the hot sitz, together with large warm enemata for thorough cleansing of the colon and relief of the pain. Oil enemata may be given at night to be retained over •night or for several hours. A number of other measures not hydriatic in nature may be conveniently combined with hydrotherapeutic treatment. Among these are the following: Abdominal massage, spinal nerve stimulation, special exercises to strengthen the abdominal muscles, vibration to the abdomen, faradic electricity to the CONTRAINDICATIONS 299 abdomen and spine, also sinusoidal electricity and the Morton wave from the static machine. Some of these forms of electri- cal stimulation may be applied by means of a rectal electrode and an abdominal sponge. All exercises which strengthen the abdominal muscles should be utilized, such as walking-, rowing, horseback riding, bicycling, etc. Contraindications to Excitant and Stimulating Measures. 1. Old age. 2. Infancy. 3. Arterio-sclerosis. 4. Acute mania. 5. Tuberculosis (pulmonary). 6. Emaciation. 7. Thin diabetic patients. 8. Bright' s disease. 9. Exhaustion from any cause. 10. Hemorrhage. 11. Severe coughing. 12. Asthma. 13. Emphysema. 14. Organic heart trouble. 15. Chorea. 16. Extreme neurasthenia. CHAPTER XXI SEDATIVE EFFECTS MEASURES which reduce or check the over-activity of an organ or function are said to have a sedative effect. Since there are many organs and functions, one might so elab- orately classify sedative effects as to prove confusing, and so lose the distinctive principles governing hydriatic sedatives. Any application must of necessity affect more than one struc- ture, as we have learned concerning tonic measures; but we have also learned that every application has its predominating effect. For the sake of clearness we shall, therefore, here dis- cuss only nerve sedatives — those measures which relieve irrita- tion, nervousness, spasm and convulsions, and are conducive to rest, relaxation, or sleep. The principal sedative measures may be classified as follows: — I. GENERAL SEDATIVES. 1. Pure sedatives. 2. Tonic sedatives. II. LOCAL SEDATIVES. 1. For the relief of pain (analgesics). 2. For the relief of paraesthesia. The first (I) employs mild hypnotic, calmative, and anti- spasmodic means, and mild tonics almost entirely. The second •(II) must, of necessity, employ extreme means, since pain and abnormal sensations can not be relieved by mild applications. GENERAL SEDATIVES 1. Pure Sedatives: Temperatures at or not far removed from neutral. (300) GENERAL SEDATIVES 301 (a) Neutral or warm bath 94° — 98° F. (b) Neutral wet sheet pack. (c) Continuous flowing- bath. (d) Oxygen bath. . (e) Warm or hot shower, spray, douche, or affusion. (f) Neutral pour to spine. (g) Sponging- — cool, tepid, or warm. (h) Heating compress, as moist abdominal girdle, spinal com- press, throat compress, moist chest pack, etc. (i) Fomentations moderately hot, especially to spine and abdomen. In addition to the above, the following sedatives are espe- cially directed toward decreasing the congestion of nerve centers. (a) Hot foot bath with cold to the head. (b) Cold sitz bath. (c) Cold water coil to abdomen or head. (d) Alternate hot and cold percussion douche to feet. It will be noticed that all of these measures, unless it be the neutral bath, secure sedation by combining the purely sedative effects with that of derivation. For example, the hot foot bath with cold to the head produces sleep and relieves nervousness and headache by reducing cerebral congestion. The wet sheet pack at 65° — 70° F., given alone or followed by a graduated shower at 95° — 90° F., is effective because of the relief of cerebral hyperemia which it produces, combined with pure sedation. Relative to the effects of the cold wet pack, Baruch l says: — The experiments of Max Schiiller and the observations of Mary Putnam Jacobi have so clearly demonstrated the calming influence of the wet pack upon the cerebral circulation that we have an exact basis upon which this treatment may be applied in many cases of neurasthenia, especially those tixrablesome cases in which insomnia is a pronounced manifestation. ' This procedure is one of the most effective means of quiet- ing the entire nervous system, whether the irritable condition be due to an essential increase of reflex excitability or to a cere- 1 Principles and Practice of Hydrotherapy, p. 440. S02 SEDATIVE EFFECTS bral hyperemia. The pronounced sinking of the brain sub- stance, the positive diminution of the respiration and heart beat, the weakening of the reflex excitability and of activity of the cerebral ganglia observed in trephined rabbits during the wet pack, combined with the positive diminution of the vessels of the pia mater, represent the fundamental conditions for physi- cal calm and sleep. These are probably also present in man during the wet pack. Sleep is accompanied by a decided dim- inution of blood in the cerebral vessels; indeed, the latter has been accepted as an essential condition for the production of sleep. This may explain why the wet pack, properly applied, is a useful procedure in the insomnia of neurasthenics." The cold sitz, cold coil to the abdomen, etc., produce sedation by reducing congestion of the sympathetic ganglia of the abdo- men and pelvis. Fomentations to the spine withdraw blood from the spinal cord, and the heat is in itself relaxing and de- pressant. Heating compresses are mild derivatives and com- bine with this derivation a neutral temperature. All antipy- retic measures are in the nature of the case antispasmodic and hypnotic, since they lessen toxemia and so relieve the nervous system. Cold sponging is sedative in both actual fever and feverishness. Hot sponging is usually most effective in condi- tions purely nervous. In acute mania the wet sheet pack is a most excellent means, and serves a double purpose in restrain- ing the patient while applying the neutral temperature. Indications for the Use of Pure Sedatives. 1. Insomnia. 2. Agitative neurasthenia. 3. Hysteria. 4. Mania. 5. Chorea and choreiform diseases. 6. Paralysis agitans. 7. Spastic spinal paralyses. 8. Epilepsy. 9. Locomotor ataxia (first stage). 10. Nervousness due to congestive headache. 11. Clonic and tetanic spasms from various causes. TONIC SEDATIVES 303 Precautions. The personal factor or idiosyncrasy has much to do with the selection of a sedative treatment. If a patient has taken a dislike to a certain measure, it is likely to produce agitation rather than sedation. Sedative effects are likely to be transient, and so the treatment must be frequently repeated. With neurasthenic patients a treatment which may have given good results in a certain case may be robbed of its effect by some unusual occurrence which may seem trivial in itself, such as slight alteration in the manner in which it is given, or the changing of an attendant. 2. Tonic Sedatives. Insomnia and nervousness may be due to a lack of normal fatigue such as follows active work, espe- cially out of doors. This is particularly true of those in seden- tary occupations, such as professional, business, and office men. These persons may be of fairly good physique and health other- wise. It also occurs in enforced idleness, as after fractures, operations, etc., and in the case of chronic invalids. The rational treatment consists in the production of fatigiie. Where possible, of course, exercise in the open air is the most efficient means of producing fatigue. Mild tonics are usually all that can be well borne. A few cases may be given even the most vigorous treatment. The following are the means most used as tonic sedatives: — (a) Hot and cold to the spine. (b) Wet hand rub. (c) Cold mitten friction. (d) Hot and cold spray, shower, or douche. (e) Neutral faradic tub. (f) Massage. (g) Rapid faradic current. The indications have been outlined above. Some of the prin- cipal conditions requiring tonic measures in order to produce sedation are, — 1. Insomnia. 2. Neurasthenia. 3. Splanchnic neurasthenia. 4. Chronic rheumatism. 5. Paralyses (flaccid). 304 SEDATIVE EFFECTS LOCAL SEDATIVES 1. Analgesics (relief of pain). For the purpose of relieving pain, extreme hot or cold applications are absolutely essential. Just which shall be used depends upon the particular cause and condition in each case. Some aim at the cause and others at the immediate relief of the pain, where the cause can not be removed in a short time. For the relief of pain, hot applications are usually employed. We say that heat has a specific pain-relieving effect. This is true; but it must be remembered that the relief of the pain is due to the production of definite circulatory changes which re- move the cause of pain. In inflammatory states the cause of Fig. 56. Diagram to show the effects of heat and cold in lessen- ing the pain of inflammation. ( Brunton.) pain is to be found in pressure upon nerve filaments occasioned by the congestion and heightened vascular tension. By deriva- tion, heat reduces the congestion or it relaxes the tension, and thus the cause of pain is removed. When properly applied, cold may accomplish the same results. These principles are well illustrated in a diagram devised by Lauder Brunton.2 ' The diagram (Fig. 56.) is supposed to represent the end of the finger. The small star indicates the point of irritation, e.g., a prick by a thorn. The line in the center of each finger is intended to represent the nerve going to the injured part; and at the side of each figure is an artery and vein connected by a capillary network. In a the capillary network around the 2 Therapeutics of the Circulation, p. 174. ANALGESICS 305 seat of irritation is seen to be much congested; the nerve fila- ments are thus pressed upon, and pain is occasioned. B repre- sents the condition of the finger after the application of cold to the arm or hand. In consequence of the contraction of the afferent arteries, the finger becomes anemic; no pressure is ex- erted on the nervous filaments, and pain is alleviated. C repre- sents the finger after it has been encased in a warm poultice; the capillary network at the surface of the finger is dilated, and the blood is thus drawn away from the seat of irritation, and the pain therefore relieved." For the relief of pain the following treatments are useful: — (a) Very hot fomentations. (b) Hot immersion, foot bath, sitz, etc. (c) Hot pack, local or full blanket pack. (d) Hot enema. (e) Extreme cold, as ice bag, ice compress to painful part or over artery supplying the part, use of ice water or cracked ice by mouth. (f) Cold immersion, as of a hand or foot, sitz bath, etc. (g) Derivation. (h) Fluxion by alternate extreme hot and cold applications. The indications for the use of pain-relieving measures are numerous. Pain of deep-seated inflammation. Pain of superficial inflammation. Gastric ulcer. Rectal ulcer. Hemorrhoids. Toxic neuralgia. Inflammatory neuralgia. Tenesmus — rectal or vesical. Dysmenorrhea. Colic — renal, biliary, intestinal. Burns. Sprains, bruises, etc. Fractures. 2. Relief of Paresthesias (abnormal sensations, such as burn- ing, smarting, itching, crawling sensations). 20 S06 SEDATIVE EFFECTS (a) Ice bag". (b) Immersion in cold water or ice water. (c) Very hot sponging:. (d) Stupes. (e) Weak chemical irritants, as neutral saline bath, bicar- bonate of soda bath, saline sponging, alcohol rub, witch-hazel rub, menthol compress. (f) Short sweating bath followed by tub shampoo and cool bath. Indications: — 1. Pruritis from various causes.- 2. Hives and heat rashes. 3. Formication. 4. Numbness and tingling1. 5. Burning and smarting. INSOMNIA Baruch not inaptly styles the insomnia of neurasthenia an opprobrium medicorum. If one were to form an opinion from the bad effects of medicinal treatment and the frequency with which such treatment is used, the condition is indeed a dis- credit to scientific medical practice. The insomnia accompany- ing' neurasthenia is due to a peculiar association of nerve exhaustion with hyperirritability. Doubtless nerve poisons from auto-intoxication play a large part in. the causation. It would seem that congestion of the cerebral and spinal centers is also a cause of nerve irritability and sleeplessness. It is present in the majority of cases. Because of the lack of nerve tone, general tonic treatment, as outlined for neurasthenia, is quite as essential as sedative measures which aim principally at the insomnia. In many patients, lack of normal fatigue is the chief, if not the sole cause. In such cases a mild or even a vigorous tonic treat- ment given about an hour before bedtime will produce the best results. With some persons brisk exercise to the point of moderate fatigue, taken just before retiring, will accomplish the same results. We have principally to consider the insomnia due to increased INSOMNIA 307 reflex excitability and unusual irritability of the nerve centers. The condition may be perpetuated long- after removal of the first cause has been effected. This is especially true of those patients who " can't go to sleep " because of constant worrying about their inability to sleep. These persons are the bane of the neurologist's life. They are exceedingly introspective and often almost hysterical. In order to decrease reflex excitability it is necessary to remove as far as possible all external stimuli and at the same time decongest the spinal and cerebral centers. For these purposes the ideal means is found in the neutral bath or pack. The body is enveloped in a non-irritating medium, the skin is slightly warmed and both the skin and the skeletal muscles relaxed. The temperature of the neutral bath should be not less than 94° F. and it is often better to use water a little warmer, say 96° or 97° F., since the warmth secures a full relaxation. The bath should be given in a quiet, fairly warm room and last for fifteen or twenty minutes to a half hour or longer. The disturbing effect of drafts may be avoided by stretching- a sheet across the top of the tub. It is well to lower the temperature of the water two or three degrees just at the close of the bath. A patient should never be put into a neutral bath with cold feet. All parts of the body should be warm beforehand. The neutral bath or warm bath has an effect similar to the neutral pack in causing the sinking of the brain substance. The rationale of the wet sheet pack has already been explained. With many patients it is the most efficient means that can be used. By means of woolen blankets the covering of the pack can, by an observant nurse, be so regulated as to be kept constantly at the neutral stage. The feet should be more warmly covered than the upper part of the body. An exceedingly restless patient who has had but little sleep for weeks may sleep for hours or all night in a neutral pack. For cases of agitative neurasthenia with insomnia we have recently found the oxygen bath more efficient than any other means. The temperature of the water should be 97° or 98° F. since the oxygen g-as produces a slight anemia of the skin. For the same reason it is well to precede the bath by a hot foot 308 SEDATIVE EFFECTS bath or fomentations to the spine. The bath itself lasts twenty minutes. No pour or shower or any other stimulating- measure should be used after it. The bath should be taken in the late afternoon or early evening-, never later than 7:30 p. M. It may be used daily, but it seems to give as good or better results administered three times a week only. The method and other effects are described under technique (q. v.). The salutary effects of a drug-less sleep are felt all the next day. There is not the usual after-tendency to drowsiness. The patient feels like himself. Quite the contrary condition follows the rest obtained by trional, the bromides and other hypnotics. The patient is likely to be drowsy during- the suc- ceeding- forenoon. For this reason medicinal soporifics' often defeat their own end. The patient must be kept awake during the daytime so that natural fatig-ue may result and thus the system demand rest and sleep. There are many other measures which will be found useful. The milder types of insomnia respond very quickly to a set of three fomentations to the spine given just at bedtime. If thought best, this may be followed by a light rub either to the spine alone or to the body generally. The tepid spinal affusion has an effect similar to the spinal fomentation. It should be applied to the lower dorsal and lumbar spine. Some cases of insomnia seem to be due solely to cerebral hyperemia. This is common in brain workers. In these cases the feet are almost invariably cold. If the unbalance is extreme, a very hot foot or leg bath with cold to the head should be given for about ten or fifteen minutes. This should be followed by an alternate hot and cold percussion douche to the feet. Sometimes the latter will accomplish the results as well when given alone as following the hot foot bath. The vigorous fluxion produced in the feet by the combination of percussion with thermic stimuli • results in more permanent cerebral derivation than a hot foot bath alone. The moist abdominal girdle is an excellent adjunct to a sedative treatment. As shown by the experiments of Schiiller, it lessens the filling of the cerebral vessels. It may be used after any of the treatments recommended above. It shoulcl.be CHOREA 309 worn all night. If properly applied, it will be dry or nearly dry by morning-. If, because it does not promptly "warm up," chilliness results, it must be removed. With some patients it produces " fidgets " and for this reason must be discontinued. Of tonic sedatives designed to aid in producing normal fatigue, the following- may be used in insomnia: Hot and cold to the spine, the cold mitten friction, the alternate spray or a short electric light bath followed by a spray. The neutral faradic tub followed by a short massage gives good results. Either one may be used alone. The mild exercise occasioned by dry faradism or the faradic tub is often sufficient to induce sleep. In the management of most cases of neurasthenic insomnia, it is best to give a tonic treatment in the forenoon, reserving sedative treatment and massage for the afternoon or evening. Following the plans outlined above, or similar methods, carefully adapting the treatment to the needs of the particular case under observation, can not fail to produce cure provided the patient fully commits himself to the judgment of the physician and remains long enough to secure permanent results. CHOREA The common or Sydenham's chorea is the form especially considered here. This is the type which is associated with rheumatic fever and endocarditis, occurring from five to twenty-five years of age and most frequent between the ages of five and fifteen. It may also occur during pregnancy. The cause is not definitely known. The chorea movements are sharp, decisive, and irregular. Huntington's chorea is also benefited by the methods outlined below. The condition demands a period of absolute rest in bed with freedom from all excitement. Chorea can best be treated in an institution away from friends and relatives. All possible sources of auto-intoxication, such as bad diet and constipation should receive special attention. The hydriatic management, while very simple, is of great importance. During the period when perfect rest is demanded, pure sedatives should be used. Of these the neutral bath is most efficient. It should be given S10 SEDATIVE EFFECTS once or twice a day and prolonged from twenty minutes to an hour. The bath should feel warm, having a temperature of 96° or 97° F. On the alternate days the oxygen bath may be substituted with good results. The wet sheet pack may also be used, being kept at the neutral stage. It should last about the sams length of time as the bath, or the patient may be allowed to sleep in it and be removed later with a wet hand rub. After some improvement has been secured, in a week or ten days, other sedative means which combine with them mild tonic effects may be used. These should at first be very mild, such as a wet hand rub, tepid sponging, and the neutral spinal affusion or pour. The heating abdominal compress or moist abdominal bandage may give good results. Fomentations to the spine, followed by the cold heating compress for fifteen to twenty minutes is an excellent sedative. During the entire course of treatment, the neutral baths or packs should be con- tinued. When convalescence is well established the cold mitten friction, cold towel rub, graduated and alternate sprays may be used, also light massage. All of these measures serve to remedy the anemia; even the neutral bath is helpful in this direction. The beneficial effects of outdoor life in the country, sunshine and fresh air can not be over-estimated. In case chorea is complicated by endocarditis, the same system of treatment should be followed as outlined for the en- docarditis of rheumatism. The only alteration necessary is the substitution of sedative treatment once or more daily for some of the tonic treatment, such as the cold mitten friction used in rheumatic endocarditis. PARALYSIS AGITANS While this is considered an incurable affection, the patient may be much benefited and the progress of the disease stayed for quite long periods of time by general h)'gienic management combined with sedative and mild tonic hydrotherapy. The measures recommended above for chorea are all helpful in shaking palsy. Dana3 especially recommends the lukewarm (neutral) bath and mild massage. Oppenheim4 has seen 3 Text Book of Nervous Diseases. 4 Diseases of the Nervous System. SPASTIC PARALYSES 311 improvement following- the use of the faradic bath. Vibrating chairs or vibrating- machines adjusted to give a fine rapid move- ment may show good results. Outdoor life in the woods and country are especially beneficial. SPASTIC SPINAL PARALYSES There are a number of lesions of the cord which ultimately result in degeneration of the upper motor neuron, chiefly in the lateral column. The inhibitory control from the cerebral cortex being cut off, a condition of spastic paralysis results, i. e., a loss of control associated with rigidity and spasticity of the muscles. Such a condition occurs after various forms of myelitis, especially a transverse myelitis, also in amyotrophic lateral sclerosis. If there is an acute onset as by trauma or in- flammation, as frequently occurs in myelitis, the patient must be put to rest, either absolute or partial, according to the nature and needs of the case. In some cases gentle spinal ex- tension should be used for some weeks and perfect quiet ob- served. Ip other cases, the patient may be allowed to move about the bed. During this time spinal fomentations may be applied twice daily, followed by the heating spinal compress. The warmth of the limbs should be maintained by the hot foot bath or hot water bottles. It is necessary that the patient be given tonic treatment to keep up the nutrition and invigorate the circulation. These must, however, be quite mild, such as the wet hand rub and moderately cold mitten frictions. Later, light massage to the limbs may be used. As soon as the necessity for absolute rest is past, in the chronic stage when spasticity becomes marked, nothing has proven so helpful as the prolonged neutral or warm bath. In those cases in which cure is possible this measure is almost a specific. The patient should be made very comfortable in the tub by using a sheet hammock, rubber pillows, etc. The temperature of the water should be from 95° — 97° F. It must feel slightly warm to the patient. At first the bath may be twenty minutes to an hour in length, gradually increasing the time up to three or four hours of continuous immersion daily. Even six hours in the neutral bath may prove beneficial. S12 SEDATIVE EFFECTS Where the necessary facilities can be had, the continuous flow- ing bath is a most grateful substitute. The gentle motion of the water appears to add much to the effect. The salutary effects are manifest in a lessened degree of rigidity, the limbs become more supple and can be separated to a greater extent. In order to obtain any permanent benefit, the patient must submit to treatment for many months. In the subacute stage, positive galvanism to the spine may be useful. During this time mild alternating hot and cold applications may be used to the part of the spine affected. Later in the disease, prolonged neutral baths give better results. LOCOMOTOR ATAXIA In the treatment of tabes dorsalis, we are concerned chiefly with the first two stages, the initial or pre-ataxic and the ataxic. . In the paralytic or third stage, there is little that can be done except to make the patient comfortable and treat symptoms as they arise. In the pre-ataxic stage the patient must be put to rest. This may be accomplished by restricting or prohibiting exercise. It is usually best to proscribe exercise altogether for a time. The wheel chair may be used or, if thought best, the patient may be put to bed for two or three months. Simple, regular habits are imperative. During the period of rest, the patient may be treated by fomentations to the spine, cold mitten frictions and the warm bath. Dana recommends that this latter be given for ten to twenty minutes daily and followed by a single cold pour to the spine and rubbing. The object of treatment during this stage is to keep up the patient's general nutrition and afford rest, both mental and physical, so as to relieve the tax on the spinal nerves. If the progress of the disease can be stayed, the treatment outlined for the ataxic stage may be ventured upon, beginning mildly. The Fraenkel exercises may now be begun. These should at first consist of the more simple movements and the effort restricted to a few minutes. Later on, as coordination improves, they may be more prolonged and made up of more complicated exercises. LOCOMOTOR ATAXIA 313 Vigorous spinal tonics should be used during the ataxic stage unless the patient is becoming rapidly worse. Alternate hot and cold to the spine by means of the fomentation and ice may be used daily, or this may alternate with the Charcot (cold per- cussion) douche to the spine, or hot and cold douche to the spine. These applications should be persisted in for months. The long static spark to the lower spine and legs may be used at the same time, say thrice weekly. Galvanic currents are also beneficial. It must be remembered that not all cases are susceptible of any marked improvement. The plans outlined above have proven very satisfactory in the hands of many neurologists. Nearly all agree that mercurial treatment is harmful unless symytoms of active syphilis still exist. Even in this case bad results have frequently been reported, and some observers believe that antisyphilitic medication may be the direct cause of tabes. For the arthritic complications ( Charcot' s joint) alternate hot and cold applications for the purpose of maintaining the local nutrition and improving the circulation will be found helpful. These may be given by means of the revulsive compress, alter- nate pours, or alternate hot and cold immersions. Surgical treatment has proven useful in skilled hands in remedying the deformities and restoring the usefulness of the affected joint. For painful joints, very hot fomentations may be given, fol- lowed by the heating compress. The treatment of the various crises is unsatisfactory. They may at times be relieved by local hot applications. All forms of treatment, including hypnotics, may fail. The same may be said of the lightening pains. Building up the general vital- ity of the patient will tend to remedy these distressing condi- tions. PARENCHYMATOUS GOITER The pathology 5 and morbid physiology of parenchymatous or exophthalmic goiter must be fully understood if medical treat- ment is to be conducted to produce the best possible results. Exophthalmic goiter is now considered to be due to hypertrophy 5 See articles on goiter among Collected Papers by the Staff of St. Mary's Hospital. 1905—1909. S14 SEDATIVE EFFECTS and hyperactivity of the thyroid gland. The disease is better described as hyperthyroidism. The thyroid is one of the duct- less glands producing an internal secretion. The exact chemi- cal nature of this secretion is not known. It is believed to be closely associated with some iodine compound. It is one of that class of substances known as chemical messengers or har- mones. It exercises a special influence over certain functions. In infancy the absence of the gland is marked by the condition known as cretinism, in which both the mind and the body re- main in an undeveloped state. In adult life atrophy or removal of the gland produces the condition known as myxedema, or cachexia strumipriva. In these conditions mental activity is below par, cerebration is exceedingly slow and all bodily move- ments are deliberate and physical activity much depressed. The opposite condition, known as hyperthyroidism, caused either by hypertrophy of the glandular tissue or by giving large doses of thyroid extract, produces a train of symptoms just the opposite of the above. The patient is nervous, restless, irrit- able, and may be subject to insomnia. There is a fine tremor of the fingers when the hand is held away from any support with the digits spread. During the early part of the disease, mental activity is excessive, ideation is rapid, and all the brain functions are increased in acuity. If intoxication becomes in- tense, the pulse may be very rapid, running from 100 or 120 to 160 or more per minute; the skin is usually warm and moist, being covered with perspiration the most of the time. The blood-vessels are dilated. Catabolic changes are increased and hastened as shown by the fever and increase in the excretion of nitrogen. There is a feeling of languor, and asthenia may be- come very marked. In the gland itself, the colloid material is deficient in amount, there is an increase in the number of secreting cells, even to the filling of the alveoli with cells; the blood-vessels of the gland are dilated and may be increased in number. Later, the parenchymatous cells degenerate (cyto- lysis) liberating a large amount of thyroid secretion; the most aggravated symptoms may be present while this is going on. The stethoscope applied over the gland frequently detects a sys- tolic bruit. Owing to this increased vascularity and the hyper- HYPERTHYROIDISM 315 trophy of the parenchytnatous tissue, the thyroid is enlarged. Later in the disease the eyes become prominent, the lids are closed with difficulty, and the" eyes feel dry. It is supposed that the exophthalmia is due to dilatation of the blood-vessels in the orbit. It will be seen that these conditions set forth the necessity for treatment directed toward decreasing and depressing the activity of the thyroid gland. In the spontaneous cure of this condition, the colloid material increases in amount, pro- ducing pressure upon the parenchymatous cells, thus causing their atrophy. The increase of the fibrous stroma of the gland has the same effect. In these facts lies the rationale of the beneficial action of the X-ray. It has a specific effect in des- troying or causing atrophy of highly differentiated tissue, while it favors the production of connective tissue. X-ray exposures should not be given so frequently as to cause unduly rapid dis- integration of the secreting cells, in which case thyroid intoxi- cation may ensue. The vascularity of the gland must also be decreased. Albert Kocker makes the following statements: 6 "By reduc- ing the hypertrophic thyroid tissue or reducing its blood supply, we reduce the possibility of too extensive reaction to the pri- mary cause and also enable the gland to adapt itself to coun- teract new outbreaks of primary causes which a nervous subject can easily show. ' ' The fact that increased vascularization is indispensable for the development of the disease also proves that what reduces vascularization prevents its development. At the same time it is necessary to slow the heart rate and restore the blood-vessels to their normal tone. While all cases will not respond to the same treatment, or even to different measures arranged in different ways, yet in general, the treat- ment should consist of the means making up the following pro- gram: An ice cap should be placed over the goiter almost con- tinuously or for thirty minutes to an hour from two to five times a day. These cold applications reflexly contract the blood - 6 Surgical Treatment of Exophthalmic Goiter— Journal of American Medical Associa- tion, October 12, 1907, pp. 1242—1243. S16 SEDATIVE EFFECTS vessels of the gland, thus decreasing- its vascularity and the amount of blood in the gland. They also tend to inhibit or depress the glandular activity, decreasing the formation of the internal secretion. At the same time, an ice bag should be applied to the precordia in much the same manner and for the same length of time as the ice bag to the goiter. It may be found convenient to alternate these applications, keeping the ice bag over the goiter for thirty minutes, then applying it to the heart for the same length of time, then reapplying it to the goiter; these alternations being continued more or less during the entire day. The vaso-dilatation and warm moist skin re- quire some treatment which will restore the vessels to their normal tone and check the over-activity of the sweat glands. This is best accomplished by the cold mitten friction. It should be given from one to three times daily. Many of the princi- ples governing the treatment of organic heart disease are in- volved in the treatment of parenchymatous goiter. The cold friction, by restoring the peripheral vessels to their normal tone, assists the heart action and so reduces the rate. The vascular conditions present in exophthalmic goiter and the therapeutic indications to be derived therefrom are very ably discussed by James Mackenzie ' from whom we quote the following: — ' The essential features arising from the circulation in many cases of exophthalmic goiter, it seems to me, are the abnormal and persistent dilatation of the arterioles, and a heart acting with a force relatively great to the resistance opposed. These are indicated by the rapid and forcible pulse-wave felt by the finger, and the visible pulsation of the superficial arteries and the carotid. The corresponding sphygmographic features are a high upstroke and a rapid fall, so that the dicrotic notch is near the base line. The rate of the pulse may be greatly in- creased, up to 140 to 160 per minute. The same factors — the unusually forcible injection of the blood into the arteries of low blood pressure— are present in aortic regurgitation. Though the beating of the carotid is due to similar causes in the two cases, the low arterial pressure at the end of the diastole is 7 Diseases of the Heart, Second Edition, p. 133. HYPERTHYROIDISM 317 different. In exophthalmic goiter the dilatation of the arterioles and capillaries is the sole cause, whereas in aortic regurgitation there is in addition the backward flow into the ventricle through the incompetent valves. The condition of the circulation in exophthalmic goiter is also comparable to that in some forms of sthenic fever, where the heart beats forcibly and the arteries are relaxed. "Another evidence of the relaxation of the arterioles is to be found in the subjective sensation of warmth felt by some suf- ferers from exophthalmic goiter. T*hey rarely complain of cold in winter, however lightly clad they are, and this is not infre- quently the cause of matrimonial disputes, for while the ailing wife feels warm in bed during winter with few blankets, the healthy husband feels the cold keenly. This feeling of warmth has supplied me with the indications for the only treatment of this class of case that I have found both grateful and bene- ficial to the patient, namely, the periodic stimulation of the vasomotor nerves by cold baths." The patient should be kept at absolute rest until the pulse has returned to nearly normal. Freedom from mental excite- ment and worry are fully as necessary as physical rest. In fact, overtaxation of the mental powers, nervous excitement, etc., are often contributing factors in the causation of the dis- ease and may constitute the immediate cause. In some cases it may seem best to employ some of the sedative measures, such as fomentations to the spine and the neutral bath. Usually both of these treatments are contraindicated. If the feet re- main cold much of the time, the alternate hot and cold foot bath or alternate hot and cold douche to the feet should be used. We have yet to see a case which has not been brought to a successful issue when these measures have been applied early, and have seen complete restoration in cases that have come under treatment later in the disease when the pulse reached 160, while the patient was exceedingly nervous and unable to sleep, and there was very marked exophthalmia together with a large goiter. Those cases which come on after thirty respond much more readily to treatment than when the disease occurs in younger adults or under twenty years of age. But it is also Sis SEDATIVE EFFECTS true there is a natural tendency to recovery among young- adults, nineteen out of twenty recovering- without much treatment but rest. Hyperthyroidism beginning in persons from eighteen to twenty years of age is likely to run a course of three or four years and end in a spontaneous cure. Opera- tive interference will be much less frequently necessary when these measures — rest, hydrotherapy, etc. — are given a thorough trial by those experienced in their use. METHODS FOR THE RELIEF OF PAIN Deep-Seated Inflammations Those treatments which have already been outlined for the relief of congestion and inflammation in internal org-ans are also most effective in relieving the pain occasioned by the inflam- mation. In the majority of cases, derivation by collateral heat, together with cold directly over the part, is used to relieve the congestion and pain. In others, hot applications alone are used. This is true of pleurisy, in which cold applications in- crease the pain. In many cases the pain is relieved best by very hot applications applied directly over the seat of pain. It has already been mentioned that cold may be used over an in- flammatory process in soft tissue, while in bony parts it is nec- essary to use hot applications directly over the seat of the pain. In the case of osteomyelitis and usually in mastoiditis, cold applications or the ice bag applied over the inflamed part in- creases the pain. When an inflammation has gone on to the formation of an abscess, cold applications, especially the ice bag-, have very little influence on the pain as far as relieving it is concerned, and may make it worse. Fomentations over an ab- scess may relieve the pain for a time, but this does not last as long as the relief afforded previous to the formation of the abscess. In order to decrease the throbbing- pain of an inflammatory process or collection of pus in the bone, it is best to apply the ice bag over the large artery supplying the inflamed part. The relief of the pain in this case is brought about chiefly by reduc- ing the congestion. If, at the same time, a very hot fomenta- tion is applied over the part, the effect is intensified by the specific pain-relieving action of the heat. RELIEF OF PAIN 319 Superficial Inflammation In the early stage of a superficial inflammation, a prolonged cold application is usually very effective in relieving- the pain. This should be accomplished by immersion in cold water or ice water or by the use of the ice bag. Later on, it will be found that very hot applications more effectively relieve the pain. Either very hot fomentations or hot immersion may be used. Sometimes the neutral or warm pour is very grateful, there seeming- to be an added effect from the affusion that is not ob- tained by quiet immersion. The production of fluxion by alter- nate extreme hot and cold immersion is productive of good results where there is not much throbbing pain. Gastric or Duodenal Ulcer It is often the case that the pain is worse during the time that there is little, if any, hemorrhage from the ulcerated sur- face. In case hemorrhage of any moment occurs, it is neces- sary to use some cold applications, such as cracked ice by mouth or the ice bag over the stomach. Otherwise, the pain is best relieved by very hot fomentations applied to the epigas- trium, or the full hot trunk pack. These applications my be followed by either the moist abdominal girdle or by the heating wet sheet trunk pack. The effect of these applications is tore- lax the musculature of the stomach and so, by decreasing peri- stalsis, relieve the pain incident to muscular contractions. Rectal Ulcer The same principles apply here as above. The pain is most effectively relieved by applications which relax the bowel, thus decreasing the movement and consequent irritation of the ulcer- ated surface. This may be accomplished by the hot enema or fomentations. Usually the hot sitz bath is much more effective. Hemorrhoids Two different plans may be followed in relieving the pain occasioned by rectal varicose veins. Very hot applications are effective in relieving the pain, but these have no tendency to decrease the size of the hemorrhoids. On the contrary, they 320 BED A TIVE EFFECTS may increase the dilatation of the veins, stasis of blood and con- sequent pain. Of the hot applications which may be used, the very hot sitz bath is most effective. In case facilities for this are not at hand, fomentations may be used. For permanent results, we prefer cold applications, such as the prolonged cold sitz bath, ice bag- to the perineum, also the hot and cold perineal spray. To be effective, these treatments should be repeated once or twice daily for several weeks. The temperature of the cold sitz bath may be decreased gradually as the patient is able to bear it. Neuralgia The classification of neuralgias into two types has. aided in the treatment of this condition. Simple neuralgias, not due to pressure from tumors, exostoses, etc., we have classified as either toxic or inflammatory. By the term toxic, we designate such neuralgias as are due to rheumatic (uric acid) diathesis, or some form of auto-intoxication. The essential element in the causation of this form of neuralgia is the circulation of tox- ins in the body, or the accumulation of toxins about nerve centers or nerve trunks. By the term inflammatory neuralgia, we understand such conditions as are due to actual inflammation, usually such in- flammations as pass through the regular stages of an inflamma- tory process, from acute to chronic.8 It may often be difficult, impossible, and in some cases, unnecessary to make these dis- tinctions. It will be readily understood that some of the changes occurring in an ordinary inflammation are produced by the accumulation of toxins about nerve trunks. Local edema of tissues occurs in both cases. 1. Toxic Neuralgia. Where there is a local accumulation of toxins about a nerve trunk, it appears that hot applications most effectually relieve the pain while cold increases the pain. Nitrogenous extractives and other nitrogenous toxins are sol- uble with difficulty. They are more readily dissolved in hot water. Since prolonged hot applications raise the local tem- 8 The term inflammatory neuralgia is not intended as a synonym for neuritis, such as alcoholic neuritis, which latter results in nerve degeneration and gives the R. D. on electric test. NEURALGIA 321 perature of the part treated, it might be supposed that the tox- ins are rendered more diffusible, and hence may be gotten rid of more rapidly. The chilling: of the tissues would result in a greater precipitation of these sparingly soluble substances and so tend to increase the pain. It must, of course, be remem- bered that heat 'has a specific pain-relieving action which is possibly greater in importance than any action it may have upon the local accumulation of toxins. The pain of toxic neu- ralgia may be relieved by very hot fomentations or the local electric light bath. For a prolonged application, the hot water bottle is very serviceable. Any of these applications may be followed by the heating compress. This should be wrung from tepid or cool water; rarely, if ever, from ice water. The mode and duration of the hot application should be varied according to the character and location of the pain. In treating sciatica, the hot fan douche is a very effective means. Very hot affusions may be used. Sometimes the hot percussion douche is more effectual. It must always be borne in mind that the cure- of the case requires the entire removal of the cause. For this reason, a regime embodying the prolonged use of tonic hydrotherapy, general eliminative treatment, and proper diet, is necessary for the permanent relief of neuralgias. We have found the use of positive galvanism of very great benefit in neuralgia, especially in facial neuralgia of severe chronic type. 2. Inflammatory Neuralgia. A very different plan should be followed where the pain in nerve trunks is due to real inflam- mation. Prolonged cold applications, even to almost freezing the part, give better results than hot applications. For this purpose, it is sometimes recommended to use the ethyl chloride spray. Cold may also be applied by means of the ice bag, ice pack or ice compress. These should not be too thickly covered and should be left in place a sufficient length of time to mater- ially lower the temperature of the part treated. Sometimes derivation by direct cold and collateral heat is very effective. Cold affusions may also be used. The pain of an inflam- matory sciatica is often benefited by the alternate hot and cold 21 S22 SEDATIVE EFFECTS douche applied up and down the thigh over the sciatic nerve. In all cases of neuralgia, it is best to make repeated search for the cause. While the majority of cases of facial and other neuralgias are not due to conditions which can b? remedied by operation, yet this is sometimes the case. In this connection, it might be mentioned that operation for facial neuralgia is, in the majority of cases, not only a failure, but an actual detriment to the patient. The relief of the pain is merely temporary and, because of shock, nerve exhaustion, etc., repeated operations render the patient much more susceptible to pain. Myalgia — Lumbago Lumbago is the most common myalgia, and is that treated of here. It follows colds and exposure to cold and dampness. The actual cause and the morbid condition are not well under- stood. The treatment differs considerably from other sedative measures, in that the best results are obtained by the most vigorous stimulation. We have obtained almost invariably un- failing results from the use of large very hot fomentations to the lumbar spine followed by the alternate- hot and cold percus- sion douche to same region and heavy massage or vibration to the large lumbar muscles. About once a day the negative static spray or short static spark may be used; also slow sinu- soidal or static surging to produce vigorous muscular contrac- tions. In acute cases these treatments bring prompt relief; and in chronic cases, in a few days or a week or two. Tenesmus, — Rectal or Vesical Pain in hollow muscular organs is chiefly due to the con- tractions of the muscular tissue. This activity of the muscular wall increases the irritation arising in the mucous membrane. To relieve tenesmus of the bladder or rectum, we have found the hot sitz bath the most effectual. The heat should be pro- longed a sufficient length of time to fully relieve the pain. Only a brief dash of cold water should be given at the close. In some cases it should be omitted entirely. Large fomenta- tions or the hot hip pack may be used. In rectal tenesmus, a small hot enema or the starch enema affords relief. The enema DYSMENORRHEA 323 should be given before fomentations or the hot sitz is applied. Cold applications stimulate muscular contraction, and hence increase the pain. Dysmenorrhea The condition here is somewhat similar to a tenesmus. It is most frequent in sharp anteflexions of the uterus, or may be occasioned by chilling-. In order to afford immediate relief, it is necessary to relax the musculature of the organ. Cold causes contractions of the uterine muscle and so prevents the out- flow of blood, while hot applications relax the muscle. Often simple fomentations are sufficient to afford relief. It may, however, be necessary to use the short hot sitz bath. No cold treatment should follow it. The application of the unwrapped ice bag to the sacrum may be used, accompanying some hot application to the feet and legs. It may be necessary to con- tinue this twenty or thirty minutes. Hot applications in front may be used at the same time. The ice bag when applied an- teriorally has the opposite effect, that is, it causes contraction rather than relaxation. Probably the explanation of the action of the ice bag to the sacrum in relaxing the uterus, as has been pointed out, lies in the fact that the posterior area is in less perfect reflex relation with the uterus; and for this reason, the reflex is easily paralyzed, the effect then being opposite to that which we usually expect from the ice bag. The use of the ice bag, however, is not as satisfactory as hot applications alone. In addition to these measures, the hot enema and very hot vaginal irrigation may be administered prior to the use of the fomentation or hot sitz. In the case of suppressed menses with pain, when due to colds or exposure to dampness, it is well to use a hot foot bath; or better, hot leg bath, together with some local hot applications. This reduces the extreme pelvic congestion, renders the outflow easier, and so relieves pain. Colic, — Renal, Biliary, Intestinal The pain of renal, biliary, and intestinal colic is largely due to spasmodic contraction of the non-striped muscle of these parts. The irritation of the mucous membrane by the calculus stimulates the muscle to contract. To relieve pain from cal- 324 SEDATIVE EFFECTS culus or the pain of intestinal colic, it is necessary to use large hot applications in order to secure perfect relaxation. 1. Renal and Biliary Colic. It is usually considered that morphine is absolutely essential in these conditions. By the use of the full hot blanket pack or hot trunk pack, morphine may often be entirely dispensed with. If the pack does not fully relieve the pain, a much smaller dose of morphine than would otherwise be required, will be sufficient. The blanket should be wrung from boiling water, quickly spread out on the bed over a dry blanket and as quickly as possible wrapped about the patient. A thin dry blanket may be used next the patient if it seems advisable. It is not necessary to include the arms in the pack. A hot-water bottle over the abdomen and spine bags along each side of the trunk will help to maintain the heat of the pack. In cases where the pain is not so severe, large fomentations may be sufficient. The full hot tub bath gives good results in some cases. Wherever a hot application is much prolonged, cold compresses should be applied to the head and neck. No cold applications whatever should follow the hot pack. Even a very brief application of cold may bring on the pain. 2. Intestinal Colic. In regard to the causation of colicky pain in hollow viscera and particularly the intestine and the region to which it is referred, Mackenzie relates an interesting ex- perience with a patient on whom he performed an intestinal re- section without anesthesia. He says, " It turned out as I had expected, and I was able to break down numerous old and recent peritoneal adhesions, to detach them from the liver and bowel, to resect a piece of bowel and mesentery, and to stitch these structures without the patient experiencing the slightest sensation. But I found that he occasionally groaned with pain when I was not touching him, and watching to see the cause I found that the upper part of the resected bowel, which was laid on one side in a warm aseptic cloth, occasionally passed into peristalsis, contracting from a wide tube to a thick fleshy rod; when this happened the patient groaned with pain. I asked him where he felt the pain, and he passed his hand invariably over the umbilical region. I started th.e peristalsis several BURNS 325 times by slightly pinching: the bowel, and each time the patient felt the pain. Here before my eyes was the cause of the pain, and the seat of origin of the pain was at least twelve inches away from the part in which the pain was felt. From this experience the following- deductions can be made : First, that the stimuli that produce pain and other sensations in the external body-wall are not adequate to produce these sen- sations when applied to the viscera; second, that violent con- tractions of non-striped muscular fibres can produce pain, but the region in which the pain is felt is different from that in which the contracting muscle lies." 9 The effect of hot applications in these cases is due to the re- flex relaxation of the intestinal musculature, and hence the relief of the pain. When intestinal colic is due to poisoning or simple diarrhea, it is well to begin the treatment by thorough" cleansing of the intestinal canal. It may be necessary to use a cathartic in order to completely remove the irritating toxic material. Castor oil is very satisfactory, especially in children, because of its con- stipating after effect. In all cases, hot enemata should be given until the lower bowel is thoroughly cleansed. If necessary, this may be followed by the starch or starch and laudanum en- ema. Following this, the most effective measure for the relief of the pain is the abdominal fomentation. These should be re- peated until the pain has been entirely relieved. The hot-water bottle may be used between treatments. Fomentations to the abdomen may be given every two to four hours or as frequently as necessary. Burns In the case of burns covering a somewhat limited area, the dressings usually applied are sufficient to relieve the pain. Cold immersion relieves the pain during the time the part is in the cold water. It has, however, been our experience that the pain is worse after removal from the water. On the contrary, while hot immersion is not very grateful during its continuance, its after effect is better than that of cold immersion. A neutral or 9 Mackenzie — Diseases of the Heart, pp. 34, 35. 326 SEDATIVE EFFECTS warm pour to the burned part is very effective in relieving- the pain. In extensive burns, it is often necessary to use a full immersion bath of either neutral or cool water. In the absence of facilities for this, a prolonged wet sheet pack, renewed by frequent sprinkling- with cold water, may be used. With the exception of extensive burns or where the pain is unbearable, we do not greatly favor the use of hydrotherapy for the relief of the pain. The use of picric acid in saturated aqueous solu- tion, followed by drying- and dusting- the part with stearate of zinc, has given such good results in the. relief of pain, rapid dermatization, and healing- that we use it as a routine treatment. Sprains and Bruises Hot applications, including- fomentations and hot immersion, are common household remedies for the relief of pain occa- sioned by sprains and bruises. These applications do effectually relieve the pain and relax the muscles. In many cases, much better results may be obtained by the prolonged cold immersion. This reduces the congestion and helps to prevent excessive ex- udation of serum into the soft tissues about the sprained part. Along this line, we may draw a practical lesson from the method instinctively pursued by wild animals. They usually seek a stream or body of cold water and stand in it for hours at a time. Whatever method is used at first, after a day or two, it will be found advantageous to utilize alternate hot and cold applica- tions, such as the hot and cold spray, pour, or immersion. These stimulate the circulation, thus hastening the absorption of the edema. Fractures There are two objects to be attained by hydriatic applications in fractures. These are the relief of the pain and the relax- ation of the muscles. The limb should be enveloped in a large fomentation or immersed in very hot water. Care should be taken that a burn or blister does not result. These methods are in too common use to need extensive discussion. It will always be found easier to set a bone if the muscles have been thoroughly relaxed by the preliminary use of hot applications. The same principles apply to the reduction of hernia by taxis. HEADACHE 327 Headache The subject of headache is such a large one that we can not enter into it here with any degree of completeness. A few principles of therapeutics will, however, be helpful in obtaining an understanding of the scientific application of physiologic therapy in the relief of this condition. In order to give these principles with the least possible repetition, we have adopted the classification of J. W. Shiels:— 10 I. Functional headaches. 1. Toxemic headaches (acute, chronic). 2. Neuropathic. 3. Reflex. II. Organic headaches. III. Circulatory headaches. 1. Anemic. 2. Hyperemic (active). 3. Hyperemic (passive). The above is very much abreviated. As given by Shiels, each division embraces from five to twelve or more individual items — the designations of morbid conditions, diseases, or pathologic states. Functional Headaches. The acute toxemic headaches of acute infections, acute nephritis, uremia, diabetic acidemia, and acute drug poisonings, are best relieved by direct and vigorous treat- ment of the causative diseases. Ice bags .to the carotids and to the base and vertex of the brain will help in relieving the accompanying congestion. The chronic toxemic headaches of gout, rheumatism, constipa- tion, torpid liver, and other diseases affecting metabolism, are also to be treated by treating the causative disease. But in these conditions it requires patient, persistent effort over weeks or months of time in order to produce satisfactory results. Out-of-door life, sunshine, and tonic and eliminative hydro- therapy will do much to remove the toxins by stimulating their oxidation. In addition to this, the measures recommended for neuropathic headaches will prove helpful in relieving or miti- 10 Shiels— California State Journal of Medicine, November, 1909, p. 401. SEDATIVE EFFECTS gating the distress until more permanent results can be secured by the removal of the cause. In some of these diseases the headache is made worse by an accompanying anemia or hyper- emia, in which case the measures recommended below for these circulatory conditions should also be used. Neuropathic headaches are relieved with ease or difficulty according as they are of short or long standing, /. e. , as to whether or not they have become habits, appearing periodi- cally. The neurasthenic headache usually responds to tonic hydrotherapy and out-of-door life. It is the form of headache which is most benefited by nerve pressure and nerve stimula- tion, spinal and head massage. It is in these neuropathic headaches that the osteopath acquires a justly obtained reputa- tion for skill. However, any thoroughly trained masseur who has acquired a fair knowledge of anatomy can accomplish the same results without the recital of osteopathic dogmas with which the osteopath accompanies his treatment and by which he ties his patient to himself and his creed, greatly to the patient's detriment in case of other or more serious maladies. Positive galvanism to the base of the brain or forehead, the positive static head breeze, or mild faradism to the head, are useful in certain cases of neuropathic headache. Migraine, in our experience, is both toxemic (metabolic), hyperemic, and in many cases reflex (from the liver, stomach, or pelvis). It is most discouraging and unsatisfactory to treat as far as immediate rejief is concerned. We have attained suc- cess only by a painstaking, diligent, and often prolonged search for the cause. If it is the expression of visceral gout, a rigidly purin-free diet with eliminative and tonic hydrotherapy, fresh air, and sunshine, continued for months or years, will ulti- mately result in a satisfactory cure. If reflex, the diseased organ or function must be sought out and treated. In all cases .out-of-door work is one of the most beneficial means of treat- ment. Organic Headaches. The headache of acute or chronic meningitis is to be treated in the same way as any headache due to acute congestion. The results are less satisfactory because of the high intracranial pressure. This factor may be HEADACHES 329 partially or wholly eliminated by spinal puncture, except in cases where the foramen of Magendie is closed. The headache of brain tumor yields but slightly to anything: except a powerful hypnotic or analgesic drug:. In all cases where syphilis may be a possible cause, potassium iodide should be used. In head- ache due to gumma of the brain, its results are satisfactory and usually prompt. Circulatory Headaches. Anemic. This is present in severe anemias from many different causes, sometimes in convales- cence, and in blood dyscrasias. It may also be caused by vascular spasm. The most satisfactory treatment is alternate hot and cold applications to the head given as described under technique. This measure occasions a more active circulation in the cerebral vessels by stimulation of the vessels themselves through their vasomotor nerves. It should be repeated daily or on alternate days as required. Alternate hot and cold to the spine and the cold mitten friction will both aid in stimulat- ing the circulation. Hyperemic. In active hyperemia the pain is often throbbing in character and the face is flushed, so that the diagnosis is not difficult. The treatment consists in depletion. This may be secured in many different ways applied as necessary according to other conditions present. The hot foot bath with ice bags to the carotids and back of the neck is a routine measure and usually results in relief. When due to excessive brain work, the alternate foot or leg bath or the alternate hot and cold percussion douche to the feet and legs is more beneficial. It produces depletion by collateral fluxion. In some cases the use of simultaneous hot and cold to the head is best designed to relieve the hyperemia, especially where there is also a toxemic factor present. Passive Congestion. This is a very troublesome form of head- ache, found chiefly in cases of cold in the head (coryza). Since passive hyperemia is best treated by fluxion, the headache present with this condition also yields best to the application of alternate hot and cold to the head, the same as recommended for anemia of the brain. This stimulates the circulation and so remedies the passive congestion. Since the brain is very SSO SEDATIVE EFFECTS susceptible to hyperemia, the treatment should be accompanied by the hot foot bath or hot leg: pack and finished by a cold mit- ten friction or the alternate hot and cold percussion douche to the feet, in order to prevent active congestion and to secure permanent derivation. In connection with the subject of headache, we can not re- frain from uttering: a caution against the use of analgesics. It is true that patients desire and often demand something for immediate relief. The relief received, the patient makes no reform, or in many cases no attempt at reform, and obscure causes are not searched out. The headache powder is repeated on the next occurrence of the headache, and in a very short time the habit is formed. It is then "a much more difficult matter to afford temporary relief without the drug, and a still more difficult matter to effect a permanent cure. The patient had better have suffered a little temporary dis- comfort and pain, and have yielded to the physician's advice in starting a search for the cause and instituting a method of treatment for its removal and the correction of the morbid habit. Practically all headaches other than organic, and even some of these, may be entirely remedied by persistent and painstaking endeavor. CHAPTER XXII EXPECTORANT EFFECTS nPHERE is a definite series of changes accompanying the course A of such conditions as colds, acute bronchitis, and simple croup. In all congestions and inflammations of the mucous mem- brane of the respiratory tract, the first change is that of intense congestion accompanied by swelling and turgescence of the mem- brane which is dry and much irritated. In this condition the cold is said to be "tight" because of the extreme irritation and the fact that the dry mucous membrane renders gaseous inter- change difficult. Very soon there begins to appear a secretion of a thick tenacious mucus, accompanied by leucocytes. Later, the character of the secretion becomes altered. It is more fluid, contains frothy mucus and is more purulent in nature. When this change occurs, the cold is said to have " loosened." From this time on, expectoration becomes easier. During the first stage of the turgescence of the mucous membrane, there is no expectoration. Later, there is a very small amount of thick mucus which is expectorated with difficulty; and after the cold has thoroughly loosened, the quantity is very much increased, while the sputum is quite fluid. In the application of measures designed to relieve these conditions, that which appears most rational is the hastening of this series of changes and relieving such symptoms as pain and cough. During the first stage, that is, the stage of congestion, and the second stage when there begins to be a secretion of thick mucus, it is necessary to decrease the congestion and increase the fluidity of the secretion. This is best accomplished by moist heat, such as the inhalation of steam, fomentations to the chest and throat, hot water drinking, the heating chest (331) SSH EXPECTORANT EFFECTS pack or some general sudorific measure. The moist heat dilates the blood-vessels and stimulates the activity of the mucous glands, so that they produce a more fluid secretion. These measures should be continued with but little change until the symptoms are considerably ameliorated. Then after the first day it is best to employ alternate hot and cold applica- tions, the revulsive compress, cold mitten friction, etc., in order to promote resolution, absorb the exudate, and prevent further excessive secretion. This is best accomplished by stimulating: the circulation, so equalizing" it that congestion of the pulmon- ary mucous membrane and the mucous membrane of the nose and throat is decreased. These measures also stimulate the depth of respiration and increase gaseous interchange. All sudorific measures ease difficult respiration and increase the fluidity of expectoration. The following are the most useful measures in the treatment of inflammations of the respiratory tract: — 1. Russian or vapor bath. 2. Inhalation of steam, plain or medicated. 3. Fomentations to chest and throat, or the hot trunk pack. 4. Heating chest pack and heating throat compress. 5. Hot water drinking. Several of these may be combined: for example, fomentations to the chest and throat may be accompanied by hot water drinking, inhalation of steam, and the hot footbath. Expec- torant effects are indicated in the following conditions: — 1. Colds. 2. Acute bronchitis. 3. Chronic bronchitis. 4. Asthma. 5. Croup. 6. Bronchiectasis. 7. Pulmonary tuberculosis. Precautions. All of the applications recommended for expec- torant effects are of a more or less diaphoretic nature, and con- sequently the patient is predisposed to colds and there is greater liability to a return of the symptoms. For these reasons, it is best to employ such measures as the alcohol or witch-hazel rub COLDS 333 at the conclusion of the sweating measure, or some mild cold application, such as the wet hand rub or cold mitten friction. The chest should be protected by a dry chest pack. The cloth- ing should be sufficient to provide warmth, and the patient should be cautious about exposure to drafts and dampness. ACUTE CORYZA, PULMONARY CONGESTION, ACUTE BRONCHITIS In these conditions, it is necessary to accomplish the follow- ing results: First, relieve congestion and pain; second, ease the cough and aid the expectoration, first by increasing its fluidity, and later, the facility of expectoration. Some general sweating measure is indicated during the first stage of a cold. The treatment already mentioned in the introduction is indicated at this time. Fomentations to the chest and throat should be repeated at intervals of three to five hours followed by the heating compress to the throat or chest, according to the location of the congestion. Fomentations also relieve the excessive cough and pain accompanying the cough. The drinking of hot water aids diaphoresis and helps to increase the fluidity of the secretion by increasing the amount of water in the blood. From the beginning of the cold, the patient should, after every hot treatment, be given a cold mitten friction or cold towel rub; and later, such treatment as hot and cold to the spine, revulsive compress to the chest, hot and cold foot bath, in order to equalize the circulation and promote return to the normal tone. In acute coryza (cold in the head) alternate hot and cold to the head may be used from the start, and repeated several times. A hot foot bath should be given at the same time. CROUP In diphtheritic croup, we are less frequently called upon to treat extreme conditions than before the introduction of anti- toxine. However, in this disease and also in simple and spas- modic croup, expectorant effects are indicated. In the latter conditions the child should be given some sweating treatment, such as a hot foot bath accompanied by hot moist applications SS4 EXPECTORANT EFFECTS to the chest and neck. This should be continued until the harsh, brassy cough gives way to free and easier expectoration . When this occurs the dyspnoea and cyanosis will be relieved. The inhalation of medicated steam is a great aid in the treat- ment. Special inhalers may be provided (Figs. 57 and 58.}, or an ordinary tea-kettle or basin may be utilized for the production of steam which may be conveyed to the patient by means of an inhaling funnel or mask. The drinking of some hot liquid will increase the sweating and hasten the loosening of the secretions. Fig. 57. Inhaler for medicated steam. (Kellogg.) The heating compress or the moist chest pack should be applied after the fomentations and left in place from thirty minutes to two or three hours. The child usually falls into an easy sleep following such treatment. In some cases it may be necessary to dispense with the moist inside part of the chest pack, using only the dry pack. ASTHMA The treatment of the asthmatic paroxysm by means of hydro- therapy is a disappointment, and this in spite of the fact that by a more or less prolonged course of hydriatic, dietetic, and cli- matic treatment, very severe cases of asthma of long standing are almost completely cured. Permanent and very decided re- CHRONIC BRONCHITIS 335 suits are obtained in cases that submit to treatment for a suffi- cient length of time. Hydriatic applications, however, may be made to assist in relieving- the patient during- the paroxysm. Two objects are to be attained, — the lessening- of the dyspnoea and facilitating- expectoration. These may be accomplished by some mild sweating- treatment, fomentations to the chest, or the inhaling- of medicated steam. As soon as the patient breaks out into a gentle perspiration, the dyspnoea begins to lessen. Pig. 58. An improved croup kettle. (Dieffenbach.) CHRONIC BRONCHITIS This condition is treated in much the same manner as any chronic inflammation. The results to be obtained are: First, relief of the cough; and second, lessening- of the amount of ex- pectoration and facilitating" its expulsion. The patient should be given a definite program of treatment, such, for example, as the following-; Hot foot bath, together with fomentations to the chest and the cold mitten friction; also fomentations or revul- sive compress to the abdomen, revulsive compress to the chest, hot and cold to the spine, cold towel rub, salt glow. It is usually best to have the patient wear some form of a dry chest pack. All of these measures stimulate the circulation, reducing EXPECTORANT EFFECTS the venous stasis in the lungs, and promote resolution. The fact that the circulation in the lungs is more rapid tends to de- crease the amount of the secretion. The patient's general vital resistance is raised by such a course of treatment. The digestion requires special attention. " Stomach cough " is not a bad name for many cases of chronic bronchitis, since the indigestion, auto-intoxication, and sluggish condition of the liver are very largely accountable for the excessive secretions. If the patient may be induced to give up all complicated dishes, desserts, meats, rich and highly seasoned foods, and limit him- self to a very simple diet, the condition will yield to treatment much more readily. The same is true of bronchial asthma. So astonishing are the results obtained in both these diseases by rigid dietetic regulation, accompanied by general tonic treat- ment, that, although requiring a long time to produce, they seem almost miraculous. CHAPTER XXIII DIAPHORETIC AND DIURETIC EFFECTS IT will be noticed that nearly all of the diseases in which diapho- retic and diuretic effects are especially indicated and where they must be used repeatedly, are intimately associated with, or due to, defective metabolism. The treatments that promote diaphoresis and diuresis all powerfully affect metabolism. Internal tissue changes are of course the antecedents of, and are manifest by, changes in excretion. It is these tissue changes and the consequent elimination of carbon dioxide and nitrogenous wastes that are of so much importance. For this reason we have devoted one chapter to a consideration of the methods and principles of diaphoretic and diuretic treatment and followed it by another devoted to the special application of these principles in systemic diseases and diseases of metabolism. DIAPHORETIC EFFECTS There are a large variety of measures which induce general perspiration. Any hot application, even if local, may induce perspiration over the entire body. The measures to be selected as most efficient in treating a disease depend upon the causes of and conditions in that disease. The following is a list of the principal diaphoretic measures: — 1. Electric light bath (general or local). 2. Sun bath. 3. Turkish bath. 4. Superheated air bath (250°— 400° F.). 5. Russian bath or vapor bath. 6. Full hot bath. 7. Hot blanket pack. 22 (337) DIAPHORETIC AND DIURETIC EFFECTS 8. Dry pack. 9. Electro-thermal pack. 10. Heating wet sheet pack. 11. Hot spray or douche. 12. Hot leg- or foot bath. 13. Hot sitz bath. 14. Fomentations to the spine. 15. Hot water drinking. 16. Hot enema. Each measure has its own range of applicability and special adaptability to the needs of the individual case. The more local and milder measures have a wide range of usefulness. The more extreme and general heating treatments have certain contraindications which must not be disregarded. Tonic cold applications should usually follow sweating treatment. The main effects of diaphoretic applications are as, follows: — 1. Increase perspiration (water chiefly). 2. Increase catabolic changes (spoliative or reducing). 3. Increase elimination of toxins through the skin and through the kidneys indirectly by relieving these organs when overworked or congested, thus making more efficient the work which is done. In health, diaphoretic measures do not increase the amount of urine and may considerably decrease it, but in all conditions where there is lessened functional activity of the kidneys, diaphoretic measures tend to produce diuresis and hasten the elimination of toxins through that channel. 4. Increase the activity of the sebaceous glands and skin in general, thus improving its nutrition. 5. Relieve internal congestion. 6. Decrease dropsical effusions. 7. Prepare the patient for cold treatment by promoting ability to react. There are a large number of conditions in which diaphoretic- measures are indicated. In a few diseases the most vigorous sweating treatments may be used with great benefit. Below is given a list of diseases and morbid conditions which require special diaphoretic treatment. Very vigorous means may be used in all but the first three. DIURETIC EFFECTS 339 Indications for diaphoresis: — 1. Icterus. 2. Systemic poisoning- (toxemia). 3. Internal congestions. 4. Secondary syphilis. 5. Obesity. 6. Acute rheumatic fever. 7. Gouty rheumatism. 8. Gout (podagra). 9. Bright' s disease, acute and chronic. 10. Uremia. 11. Eclampsia. Contraindications to extreme sudorific measures. 1. Asthma. 2. Organic heart disease. 3. Emaciated rheumatics and diabetics. 4. Sunstroke and heatstroke. 5. Pulmonary tuberculosis. 6. Asthenic fevers. 7. Icterus. 8. Emaciation and exhaustion. 9. Old ag-e. DIURETIC EFFECTS We have previously shown the close connection existing between the functions of the kidneys and skin in diseases of either of these organs. Above is given a list of the various sudorific measures. All of these treatments are beneficial in conditions of defective kidney activity. It has long- been known that nephritis and diseases of metabolism, closely associated with the functions of the kidney, are benefited by free diaphoresis. In these diseases all brisk sudorific measures indirectly increase urinary secretion. This is probably due to the fact that renal congestion is lessened, the stag-nation relieved, so that while there is less blood in the kidneys at any one time, the rapidity of the renal circulation is increased. The secretion of urine is therefore more efficient and the quantity of the watery and solid constituents is increased. The increase in S40 DIAPHORETIC AND DIURETIC EFFECTS urinary solids is due not alone to stimulation of the renal epithelium by a quickened circulation, but also to heightened metabolic changes occurring- in the tissues themselves. The stimulation of the general circulation and especially of the hepatic circulation and of the liver cells, produced by sweating treatment or accompanying the reaction to cold treatment, has been shown to increase the toxicolytic powers of the liver. Toxemia is thus lessened in a very direct manner. The blood being less toxic, irritation of the renal cells is decreased and the work done by the kidney is more efficient. The following are the principal diuretic measures which are useful in kidney insufficiency and allied conditions: — 1. Full blanket pack. 2. Electric light bath. 3. Russian and other vapor baths. 4. Hot air baths. 5. Full warm tub bath. 6. Water drinking (especially with above). 7. Cold (or hot and cold) douche to lower sternum and lumbar spine (entire width of back) . 8. Cold heating trunk pack or the rubbing wet sheet pack. 9. Fomentations to lumbar spine. 10. Intermittent or continuous proctoclysis with warm physio- logic salt solution. Indications: — 1. Bright 's disease, acute or chronic. 2. Uremia, eclampsia, and other toxemias. 3. Acute suppression of the urine. 4. Ether and post-operative nephritis. 5. Ptomaine poisoning. 6. Poisoning by lead, turpentine, alcohol, etc. CHAPTER XXIV SYSTEMIC AND METABOLIC DISEASES OBESITY IN considering- the effects of thermic applications upon tissue changes in respect to both nitrogenous and carbonaceous metabolism, it was shown that all forms of cold treatment increase catabolic changes, also that excessive heat or long con- tinued heat has the same effect. The two extremes, however, do not have the same effect upon anabolism, heat having little or no tendency to increase the building-up processes through increased absorption and assimilation of food. Tonic cold applications often increase anabolism more than catabolism. It is for this reason that cold applications signally fail in secur- ing any great reduction in weight. The patient may lose a few pounds. Of course, the general vitality of the patient and all nutritive processes are enhanced by alternating hot and cold applications. This is doubtless the more rational way to treat obesity, since it is more necessary to improve the general condition of the patient than to reduce the weight; but if the reduction of the weight is the objective point, it is necessary to resort to extreme sudorific measures, unaccompanied by cold applica- tions. For this reason it is not possible to greatly reduce the weight of persons suffering from fatty heart, accompanying the •general obesity. Spoliative and reducing measures aim at increasing catabolism without a corresponding increase in anabolism. All extreme sudorific measures available should be used in this condition. Those which will be found most helpful are the Russian bath, Turkish bath, electric light bath, full blanket pack, electro-thermal pack, and sweating wet sheet (341) Slfl SYSTEMIC AND METABOLIC DISEASES pack. The full hot bath and the mud baths commonly used at hot spring's may be used. These do not, however, have any advantage over the first three measures mentioned. The patient should have one prolonged sweating treatment daily. It is often necessary to finish with a very short cold spray. This should not be greatly prolonged for the reasons above mentioned. The patient should take as much vigorous exercise as possible. Heavy massage may also be used. It is needless to say that the following' of such a program will result in weakening- the patient, as well as in reducing the weight. These measures will all fail unless the diet is reduced, especially as regards the total number of calories. As soon as the patient returns to his usual habits of inactivity and over-feeding, there will be a prompt gain in weight which will replace all that has been lost. Extreme sweating- treatments do, however, materi- ally reduce the weight and, by guarding the diet and encourag- ing exercise, the loss in weig-ht may be quite permanent. ICTERUS It is usually impossible to employ prolonged or extreme dia- phoretic treatment in this condition, but free perspiration should be encouraged, since by increasing- the elimination of bile through the sweat, it relieves the nervous irritability and aids in relieving pruritus. Local hot applications are illy borne because of the extreme sensitiveness of the skin. The electric light bath is a very efficient means, since its heat is evenly dis- tributed. The drinking of much water is an essential for both free diaphoresis and diuresis. SYSTEMIC POISONING In many conditions in which toxic substances circulate in the blood and lymph, free diaphoresis materially hastens their elimination. Such substances may be produced by auto-intoxi-. cation from intestinal sources, or faulty metabolism. General poisoning may result from the ing-estion of ptomaines, lead, mercury, alcohol, etc. In some cases, vigorous diaphoresis is necessary; in others, only mild diaphoresis with copious water drinking- should be used. Because of the weakness and debility GOU'l 343 resulting- from the poison, extreme sweating- measures can not be used. A short electric light bath is often all that is neces- sary. Renal elimination should be hastened by free water drinking". INTERNAL CONGESTIONS The use of sudorific measures in relieving- congestion of the viscera has been considered elsewhere, especially in connection with inflammations and diseases of the kidneys. It is not pos- sible for an extreme congestion to exist in the internal organs while the skin is red and congested, as occurs in a sweating treatment. But in order to more permanently relieve the internal congestion, -it is necessary that the blood be retained in the skin. This is not accomplished by the hot alone, but can be by the reaction hyperemia resulting from a cold friction. The principle of these effects has been considered in connection with the subjects of derivation and fluxion. The relief of visceral congestions by general sudorific measures is indicated in acute nephritis, eclampsia, uremia, pulmonary congestion, acute pleurisy, and the early stages of many infectious diseases such as influenza, measles, scarlet fever, etc. GOUT AND GOUTY RHEUMATISM General Consideration The literature on the purin diathesis is most voluminous and much of it unreliable; there are, however, some important facts regarding purin metabolism that have been sufficiently well proven to allow of their being used as a foundation for the basic principles involved in the treatment of these conditions. We can not here attempt anything like a complete consideration of this question, but merely point out those facts which seem to us to be of importance in determining the treatment. There seem to be three causes for the accumulation of basic purins and uric acid in the system. These are: First, excessive ingestion of purin-containing foods over long periods of time; second, defective and deficient xanthin oxidation and uricolysis; and third, decreased elimination of purins because of kidney insufficiency. SU SYSTEMIC AND METABOLIC DISEASES To provide a diet free from purin is not difficult, and so the removal of this first cause is a comparatively easy matter. To remedy the second is, however, a more difficult matter. It has been shown how applications of both heat and cold accomplish a quite thorough xanthin oxidation, /. e. , a change of the basic purins to uric acid. This change of basic purins to uric acid is a distinct advantage, as uric acid is less irritating to the renal epithelium than the bases. " Mammals form uric acid only from the purins and have the power of destroying some of the uric acid formed. This uricolytic power is relatively weak in man."1 Nucleoproteids are converted into free purins and these, in turn, are changed into uric acid by the loss of nitrogen and the addition of oxygen. " " Wiechowski has particularly studied the enzyme concerned in the destruction of uric acid by the tissues , and the fate of free uric acid in the body. This uricolytic enzyme, which has been appropriately called uricase by Batteli and Stern, is an oxidizing enzyme, acting best in experimental digestions when a lively current of air is running through the digestion mixture, and which seems not to be present in the blood plasma and tissue fluids, but only in the cells. It acts rapidly and with striking effect, for active organ extracts are sometimes able to destroy quite considerable quantities of uric acid in a few hours; for example, one gram of powdered tissue, dry weight, can often destroy totally 0.1 gram of uric acid in four hours. Unlike the enzymes of autolytic disintegration of tissues, uricase is not inhibited by the presence of an excess of serum. Another interesting feature is that this enzyme acts reversibly, or at least tissue extracts which destroy uric acid with a current of air running through, soon build up the uric acid again when the air is shut off."* The above facts show the benefit to be derived from hydro- therapy in stimulating the circulation, increasing the oxygen- carrying capacity of the red cells, and increasing oxidation in the body tissues. Out-of-door life in the fresh air and sleeping 1 H. G. Wells— Trans. Chicago Pathological Society, May 1, 1909. 2 Editorial in Journal of American Medical Association. October 9, 1909, p. 1191: see also The Oxidases. Bulletin No. 59, p. 103. of Hygienic Laboratory, Public Health and Marine Hospital Service of the United States GOUT 345 out of doors furnishes the abundant supply of oxygen so neces- sary to uricolysis. In addition to the effects of hydrotherapy, certain articles of diet play an important part in the prevention of uricacidemia. This is notably so of fruit. " Weis, in 1898, asserted that after eating- fruit the uric acid of the urine is decreased and the hippuric acid increased." " Wohler found uric acid, but no hippuric acid, in the urine of sucking- calves, so long as they consumed nothing but milk. But as soon as they passed on to vegetable food, the uric acid disappeared and hippuric acid was substituted. It thus appears that the benzoic acid arising from vegetable diet siezes upon the glycocol and prevents the synthesis of uric acid. "it is useless merely to give benzoate of sodium, as I have proved by many experiments. But here again it should not be forgotten that it is not in our power to make the benzoic acid reach the proper point at the proper moment when the glycocol, before its union with the cyanic acid could reach it. As already mentioned, the benzoic acid in vegetable food is not generally contained as such, but is formed in the body by the decomposition and oxidation of more complex combinations. It is quite possible that these latter are taken up by the cells in which glycocol occurs, while the benzoic acid already formed is rejected."4 The use of medicinal substances in the treatment of gout, outside of those found in man's natural diet is a disappoint- ment. This is true of benzoic acid, the salicylates and also of lithium. This latter neither affects the solubility of uric acid in the tissues nor in the slightest increases its elimination by the kidneys. Even if lithium exerted an influence on the solubility of uric acid, the amounts present in commercial lithia waters would be too minute to accomplish anything. Relative to this fact, Dr. Henry Leffmann says, — ° 3 Lewellys F. Barker— Truth and Poetry Concerning: Uric Acid, p. 32. 4 Bunge— Physiological and Pathological Chemistry, Second English Edition, pp. 303, 304. 5 Proceedings of the Philadelphia County Medical Society. December 8, 1909, reported in Journal of American Medical Association of February 19. 1910. S46 SYSTEMIC AND METABOLIC DISEASES ' ' On the result of an analysis of about two score of the so- called mineral waters, the Bureau of Chemistry of the Depart- ment of Agriculture has recently issued a circular of inquiry, the essential features of which I give herewith. It has been found that nearly all ' lithia waters ' either contain only spectro- scopic traces of lithium (unweighable quantities in from 2 to 4 liters), or contain less than one part per million (approximately 0.05 grain per gallon) of lithium." Along the same line we quote6 the following from Bunge: — " If it be desired to prevent the formation of uric acid sedi- ments, or to dissolve concretions that are already formed, by the administration of alkalies, it is more sensible to advise the use of fruits and potatoes than to order alkaline mineral waters, the continued use of which may produce disturbances which we are unable to estimate. Because the combination of uric acid and lithia is more soluble in water than its combination with soda or potash, it has been thought necessary to treat the uric acid diathesis with a few decigrammes of carbonate of lithia, or even with mineral waters containing one centigram of lithia to the liter. This naive idea simply implies ignorance of Berthollet's law. We know that in solutions of bases and acids, every acid is distributed to all the bases in proportion to their quantity. It follows that only the very smallest portion of uric acid will combine with the lithia, the largest proportion combining with the preponderating quantity of soda, which we introduce as chloride of sodium. The largest proportion of lithia will reappear in the urine, united with the chlorine of the chloride, with sulphuric and phosphoric acid. There will be no increase in the solubility of uric acid." Treatment Purin diathesis, true gout, and allied conditions, such as the myalgias, lumbago, the visceral forms of gout, etc., are usually treated by extreme diaphoretic measures. It must be confessed, however, that the majority of rheumatics are not able to stand such treatment. Only those who are obese or of more than average weight can stand extreme sweating measures. It is 6 Physiological and Pathological Chemistry, Second English Edition, p. 322. RHEUMATISM 347 for these reasons that many a rheumatic patient leaves a course of baths at the hot springs in worse condition than when he began. Many and many are the patients that year after year visit the various spas of this country and Europe, deriving each time only a temporary benefit. For this, there are two reasons: All are given the same routine of hot baths, regard- less of the individual conditions and needs. Obese or ema- ciated, they are all treated alike. Second, there is a failure to eliminate from the diet all purin-containing foods and reduce to a minimum the proteid intake. Chittenden has shown that a daily ration containing 35 to 60 grams of proteid is not only compatible with perfect health, but also conducive to gain in muscular capacity, increasing the endurance to prolonged mus- cular effort and lessening fatigue. In gout and gouty rheuma- tism the proteid should be reduced to the least amount com- patible with the actual need of the body for nitrogen. As pointed out by Garrod, every particle of food not absolutely needed for the nourishment of the body merely nourishes the disease. One can not hope to cure disease unless the cause is removed. In the purin diathesis, the two chief causes are over- feeding and under exercise. The over-feeding is in the line of heavily proteid foods and foods containing purin. These must be eliminated from the diet, if great benefit is to be derived from treatment . For practical purposes, we must divide gouty jheumatism into two classes, viz., obese rheumatics and emaciated, anemic rheumatics. In the first class, sweating treatment maybe used with benefit when properly combined with tonic measures. In the second class, extreme sweating treatment is not permissible. Rheumatism with Obesity. Those patients who are well nourished may be given a thorough sweating treatment daily. Any of the sudorific measures recommended in obesity are serviceable. The Turkish bath, Russian bath, electric light bath, full superheated dry air bath, hot blanket pack, sweating wet sheet pack, or electro-thermal pack, are all applicable. Their effects may be greatly enhanced by free water drinking. The mineral waters possess no advantage over any pure water. The beneficial results are derived from the free perspiration 348 SYSTEMIC AND METABOLIC DISEASES and diuresis it induces. It thus affords ample solvent for the increased nitrogen excretion. F. Umber7 claims that alkaline water has the opposite effect; also that the blood of grouty patients is able to dissolve larger proportions of free uric acid than it ever contains. He declares that none of the alkalies or mineral waters have any specific influence on the purin met- abolism in grout and that the propaganda for the "lithium con- tent," etc., of spring's should be abandoned. Tonic measures should not be neglected. The strength should be maintained and the circulation stimulated. All hot baths should be followed by some form of cold treatment. These may at first have to be mild, but obese patients stand cold treatment well. The alternate hot and cold percussion douche is an excellent means. It serves as a massage, stimu- lates the vasomotors, and restores the tone lost because of the hot bath. It should be applied especially to the spine and legs and should consist of from three to five complete changes from hot to cold. The patient should be dried from the cold and may either rest or take exercise after it, according to the con- ditions of the particular case under observation. Individualiza- tion is the life of therapy no less with rheumatism than with other diseases. Light or heavy massage may be given. The massage douche is highly recommended by some. It possibly possesses some advantage over the percussion douche. The Turkish shampoo is an excellent means of combining massage with vigorous sudorific measures. Other tonic applications may be used, such as cold affusions and general sprays and showers. Later in the disease, the wet sheet rub may be used to advantage. Rheumatism with Emaciation. This condition is doubtless in -some cases the direct result of "hot springs" treatment. Hot treatment must be used with much caution. The vigorous sweating treatments are never to be employed if the patient is under weight. Local hot applications are permissible and a mild sweating treatment once a week may in some cases be ventured upon. Hot applications to the swollen joints, as fomen- tations, local hot air baths, superheated air (Plates XV and 7 Therapie der Gegenwart. February. L, No. 2.. pp. 73—120. PLATE XV. Superheated dry air bath. Foot bandaged in Turkish toweling ready to be introduced. PLATE XVI. .Superheated dry air bath. Treating foot. RHEUMATISM 3Jf9 , or local electric light bath should be followed by a tonic friction. At first this may be a wet hand rub with tepid water, then with cold water and later, the cold mitten friction. These frictions should be applied to the muscular portions of the body, the swollen joints being avoided. The joints should be envel- oped in heating compresses or packs wrung from cold water. These should be thoroughly covered with several layers of flannel or absorbent cotton, if necessary, in order to exclude the air. The effect may be increased by counter-irritants or anodynes. After a time the alternate soft spray douche* may be applied to the joints and the body generally. When conva- lescence is well established, the patient should be given daily some general tonic treatment with only short preliminary hot applications. In true gout, z. e., where the disease is localized in the metatarso-phalangeal joint of the great toe, the tonic measures outlined for gouty rheumatism must be used in the interval. Only hot applications can be made to the foot during the par- oxysm. At first the patient suffering from rheumatism will complain some of increased stiffness and possibly pain in the joints after even a mild cold friction. This should not deter the physician from following the plan outlined nor cause discouragement on the part of the patient. If much complaint is made, the alcohol rub may for a time be substituted. Faradization of the joints by the rapid faradic current helps to relieve the pain and the annoying paresthesias that keep the patient awake. Gentle massage of the muscles and rubbing to the spine are helps in treating the insomnia. The myalgias such as lumbago may be treated as recommended elsewhere. In lumbago, however, the most vigorous hot and cold percus- sion douche to the back should be used, followed by heavy massage or firm deep vibration to the large muscles of the back. These relieve the pain as milder measures will not. In some cases of rheumatism, notably where the patient is bed-ridden or must be closely confined to the wheel chair, it is best to follow a somewhat different plan than that outlined above. In these cases, only mildly hot local applications, such S50 SYSTEMIC AND METABOLIC DISEASES as the fomentation, radiant heat, and the hot foot bath should be used. The usual regime of cold treatment should be omitted and its place taken by carefully applied but thorough massage. This massage should include special attention to nerve stimulation, spinal and abdominal movements. The use of faradic and sinusoidal electricity for the same purpose is an addition of distinct advantage. In all cases of chronic rheumatism, special attention must be given to the alimentary tract and to the digestion. Modern investigations into the contributing causes of chronic articular rheumatism are turning more and more to alimentary stasis, intestinal infections, and auto-intoxications for an explanation of the pathogenesis of metabolic forms of chronic articular rheu- matism. In some of these cases the purin diathesis doubtless has nothing to do with the disease or at most plays only a minor part. The routine use of gastric lavage and copious enemata for a limited time may be productive of excellent results. These treatments must be thorough to be effective. Purin accumulation through defective xanthin oxidation and very limited uricolysis are a part of this auto-intoxication, and are surely to be traced to an overworked and functionally deranged liver as one source of their occurrence. BRIGHT'S DISEASE Diaphoretic measures are valuable in both acute nephritis and in the various clinical and pathological varieties of chronic nephritis. It is hardly necessary for our purpose to discuss the structural alterations occurring in the kidneys in Bright 's disease. Only in acute nephritis is there hope of any marked restoration of the normal structure. However, the functional perversions may to a great extent be corrected. The alteration .of function which is the chief, if not the sole cause of the various clinical manifestations of nephritis, is the renal imper- meability and insufficiency in the elimination of nitrogenous wastes and salines. There is also an abnormal permeability to albumen and, in some cases, to water, notably so in the inter- stitial variety of chronic nephritis. In interstitial nephritis and the kidney of arterio-sclerosis, BRIGHT S DISEASE 351 the high blood pressure is a prominent symptom and is due, at least to a great extent, to nitrogenous toxins. "Experiments on patients with chronic nephritis have shown that rich protein diet increases tension and disturbs the general condition of the patient for the worse. Miiller describes an individual in whom a change from milk and carbohydrate diet to rich meat diet caiised pressure to rise from 140 to 190. Rich meat diet causes, in nephritics, headache, one of the earliest and most constant symptoms of uremia, and one which has a definite relation to hypertension." Treatment must, therefore, be directed toward the attaining of two objects: First, decreasing the amount of toxic sub- stances and salines the kidneys are required to -excrete; second, increasing renal sufficiency, so shaping conditions that increased elimination may occur without increased strain and irritation of the kidneys. In order to meet the first indication, it is necessary to bring about several changes. The ingestion of purins (exogenous) must be stopped. The consumption of proteids must be limited as far as the needs of the system will allow. By general hygiene, exercise, etc., one may decrease the formation of intestinal toxins and promote complete oxida- tion of nitrogenous wastes. These results may be attained by regulation of the diet and attention to digestion. For a time it is well also to limit the use of salt to what naturally occurs in the food. The experiments of Strasser prove conclusively that the second object, viz. , increasing the elimination of nitrogen, salines, and water, is best accomplished by the systematic use of hydro therapy; and that what has been vainly hoped from diuretic drugs is produced by bathing. His experiments were largely with the full warm bath at 95° — 100° F. In all cases there was a decided increase in the quantity of urine and chlorides excreted, which frequently continued several days after the cessation of treatment. In no case was there a storage of nitrogen or salines on the bath days. This was true alike of cases having edema and where there was no decrease in the 8 J. H. Musser — Causes of Hypertension in Nephritis— Journal of American Medical Association, November 27, 1909, p. 1791. 352 SYSTEMIC AND METABOLIC DISEASES chlorides or nitrogen in the diet. The full warm bath fre- quently increased the elimination of sodium chloride two or three times the usual amount. In one case, increase in the nitrogen and sodium chloride of the urine occurred without increase in the total amount of urine and continued for three days after the treatment. Relative to the relation of the two crystalloids — glucose and sodium chloride — to dropsy and diuresis, some interesting facts have been pointed out by Starling. While the presence of unusual amounts of glucose in the circulating fluid induces diuresis at the expense of tissue fluids, the ingestion of much salt does, under certain circumstances, tend to increase tissue fluids and limit diuresis, producing a ' ' water-logged ' ' condition. " If a solution of 30 grains of glucose in about 30 cubic centi- meters of water be injected into the jugular vein, the first effect is a great increase in the volume of the circulating blood, brought about by the osmotic attraction of water into the vessels at the expense, first, of the tissue spaces, but ultimately of the tissue cells. The consequence of the hydremic plethora there- by induced is increased circulation through the kidneys and increased output of urine containing large quantities of sugar. . . . Under ordinary circumstances, the concentration of the tissues thus induced would produce intense thirst and an in- creased intake of water, so that the urinary flow would be main- tained at a high level until the whole excess of the glucose had been excreted." ' The ingestion of an excessive quantity of salt provokes thirst rather than diuresis. If this excessive ingestion were continued or became chronic, there would be a tendency for the amount of this salt in the body to continually increase, the salt being associated with sufficient water to maintain the molecular concentration of the body fluids at their normal height. It is not surprising, therefore, that excessive quanti- ties of salt have been found to exert a deleterious influence in cases of dropsy, or that marked benefits as regards the reduc- tion of dropsy have been attaided by the limitation of salt in the diet."10 9 Starling— Fluids of the Body. p. 153. 10 Ibid., p. 154. NEPHRITIS 353 Edema is lessened by warm or sweating- baths and sometimes very promptly. The dropsy responds even more promptly to alternate hot and cold applications to the edematous parts. The rationale of these hydriatic effects in lessening edema is a very interesting- study. We have already dwelt quite at length upon the vascular changes produced by alternating- thermic applications . Starling- has recently correlated present knowledge regarding the causation of dropsy. In the summary he brings out a number of practical points. " Ranvier has shown that if, after ligature of the inferior vena cava, the sciatic nerve be divided on one side so as to produce dilatation of the arterioles on that side, the limb in which the nerve has been divided will become edematous." There must be other factors beside venous obstruction if edema is to result. Starling- concludes that the determining cause, other than stasis, lies in an in- creased permeability of the vessel wall. This is due in dis- ease to lack of the proper nutrition and oxygen supply to the cells of the vessel wall. " Cohnheim showed that, after long continued anemia of the rabbit's ear, the vessels became so per- meable that restoration of the normal circulation was followed by pronounced edema of all the tissues." ^ The same results were obtained by Barlow. This anemia resulted in asphyxia and starvation of the cells. A long con- tinued venous stasis must affect the vessel walls in much the same way, since it also decreases the oxygen and nutritive sup- ply. In chronic nephritis there is usually a marked anemia with hydremic blood and this appears before the edema. From experiments by Bolton, one may conclude that edema results solely because of this series of changes occasioned by the stag- nation of blood in dilated veins and that plethora or increased capillary tension are neither of them necessary for the produc- tion of edema. These facts have led Starling to the belief that alterations in the endothelium of the capillary wall must be re- garded as the essential factor in the production of edema. The retention of nitrogenous wastes in nephritis must be an added cause of injury to the vessels. With these facts. in mind, the 11 Starling— Fluids of the Body, p. 159. 12 Ibid., p. 162. 23 354 SYSTEMIC AND METABOLIC DISEASES rationale of hydriatic treatment is quite evident. The restora- tion of tone to the vessels, both blood and lymph, hastens the circulation, thus relieving the stasis and consequently improving the nutrition of the vessel walls. The nutritive processes and activity of the endothelial cells are directly stimulated by hydri- atic applications. In short, the entire series of morbid changes from the decreased permeability of the kidneys to the venous stasis and increased permeability of the vessel walls, is met by the one agent — warm water. There is no evidence that free water drinking is harmful in edema where the amount of urine is less than normal. On the contrary, it has been shown that plethora is not a contributing factor in edema. The diu- resis it induces greatly lessens nitrogenous retention and thus, by decreasing the toxemia, aids recovery. Acute Nephritis. Beginning as it does as an acute imflam- mation and passing through the various stages of the inflam- matory process, acute Bright's disease should be treated along the lines laid down for inflammations. The peculiar course of the disease is governed by the anatomic and physiologic re- lations of the kidneys, organs of necessarily constant activity, and activity of such a character that it must militate against their recovery. The kidney is congested, swollen, edematous, and tense at the onset of the first symptoms; later, venous stasis is the predominating physical change. To relieve these condi- tions, sweating measures have abundantly proven their superior- ity. These congest the skin and relieve the kidney congestion. The patient' should perspire freely for an hour or more, at least once a day. 'The skin should be warm and moist all of the time. Free diaphoresis may be accomplished in several ways. It is often best to resort to some of the milder measures, such as the hot foot bath with fomentations to the abdomen or spine, or the hot trunk pack. If the symptoms are urgent, the full 'hot pack may be used. The head should be kept cool, and if the pulse is over 100, an ice bag placed over the heart. During the sweat, copious water drinking should be encouraged. This favors diaphoresis, and as soon as the. renal congestion lessens, it aids in diuresis. The patient may be sponged off with tepid water and then placed between warm blankets to continue per- NEPHRITIS 355 spiring, gently for an hour or longer. A brisk cold mitten fric- tion so given that the part treated is immediately dried, rubbed with the dry hand until warm, and then covered with the warm dry blanket, will prove a valuable adjunct to the sweating measure. It improves the general vitality and helps restore the cardio-vascular mechanism to normal tone. Frequent re- petition of the warm saline enema is unrivaled in the preven- tion and treatment of the uremia of acute .nephritis. General cold- applications, i. e., cold applied to a large surface at one time, such as the cold towel rub or wet sheet, are contraindicated. The cold mitten friction given as described above counteracts the depressing tendency of the sweating measures which must be repeated daily. The alcohol rub may be used, but it lacks the tonic effect obtained from the cold. The hot air bath, so prepared that it can be given in- bed, is an excellent means of producing perspiration (Plate XVII.}. Croftan13 objects to the use of dry heat in cases unaccompanied by edema, claiming that it increases the concentration of the blood. He favors the use of the full warm bath in acute nephritis. This should be at a temperature of 98° — 104° F., continued for ten or fifteen minutes. Others recommend a temperature not over 100° F. in subacute nephritis, and the prolonging of the bath from thirty to sixty minutes. During this time, the head and face should be bathed in cold water or cold compresses applied to the head and neck. The tub should be covered with a sheet in order to limit the cooling of the surface, and when the patient is removed, the room temperature must be 85° or more to guard against chilling. The patient should be immediately placed between dry blankets, or in a sheet and well covered by warm dry blankets and allowed to remain in this heating pack for a time. The electro-thermal pack is a very convenient substitute for the dry pack. During the first few days of acute nephritis, in case it seems necessary to use the hot trunk pack or full hot blanket pack, an ice bag may be applied over the lower third of the sternum. It tends to cause reflex vaso-constriction in the kidney. With these intensely hot applications, an ice bag over the heart is 13 Clinical Therapeutics. S56 SYSTEMIC AND METABOLIC DISEASES usually necessary and, if a large ice cap is used, it will cover the sternal kidney area as well . Other forms of hot bath , such as the Russian and electric light, may be best left for subacutc or chronic nephritis after the acute symptoms have largely subsided. Chronic Nephritis. In chronic nephritis, whether a sequel of the acute or coming on insidiously and complicated by cardiac and vascular changes, it is possible to utilize a greater variety of measures and more vigorous tonics can be borne. A southern climate is of advantage largely because free perspira- tion is secured without effort and there is less tendency to chill- ing. We have utilized with success all hot baths, such as the Russian, Turkish, electric light, and superheated air. These may be given two or three times a week. About once a week or once in two weeks, it is desirable to follow a vigorous sweat- ing treatment by the Turkish shampoo. All these extreme- sudorific treatments should be concluded by some form of the hot and cold shower, douche, or spray. The douche is the best means since it combines percussion effects with the thermic stimulus and so lessens the tendency to chilling. The alternate application of fomentations and an ice bag to the lower sternum and kidney region produces mild fluxion in the kidney. The alternate hot and cold percussion douche to the lower sternum and the lower dorsal and lumbar regions is more vigorous and a very efficient means of stimulating renal activity. Nearly all hydriatists recommend very highly the full warm bath as the most serviceable measure in subacute nephritis. While we do not doubt its great utility, yet we have seen better results. by employing, in about two out of every three treat- ments, more vigorous means and means employing more tonic- effects. These are obtained to only a slight extent by the warm bath. Where there are marked changes in the heart and ves- sels, we have found tonic hydrotherapy a necessity. Of tonic measures, one may use hot and cold to the spine, the revulsive compress to the kidney region or abdomen, the cold mitten friction, the ice bag to the heart, and the alternating douche. The Nauheim bath is highly recommended both for the relief of dropsy and the treatment of cardio- vascular disturbances. NEPHRITIS 357 That it is a powerful means can not be doubted. It must, however, be used with caution, remembering- that it may result in overs timulation. For the edema of the feet and legs, alter- nate hot and cold immersion is as valuable as for the same condition in cardiac incompetency. Its beneficial action may be assisted by massage. Cathartics and Medicinal Diaphoretics. About the only dia- phoretic drug recommended as a routine is pilocarpin. This must, however, be mentioned only to be condemned. It is dan- gerous where the heart may be involved in the general vascular changes and its use is entirely superfluous, since we have such efficient hydriatic means of accomplishing the same results. Saline cathartics or elaterium as a means of reducing ascites or anasarca may at times be necessary. Their repeated use is not to be encouraged, since they induce great weakness and derange the digestion. Diuretin should not be used in any form of ne- phritis since it irritates the renal epithelium. It is necessary that special attention be paid to gastric digestion. The measures recommended for the various forms of atonic indigestion should be used as indicated. Attention should also be given the gas- trectasia which so frequently accompanies a chronic parenchyma- tous nephritis. It is a cause of faulty nutrition and is closely connected with morbid proteid metabolism. The free use of mineral waters may greatly increase the dilatation. Fluids must be taken in small amounts, preferably as plain cold water. In interstitial nephritis, mineral waters or even the free use of ordinary water is unnecessary, since diuresis is the rule. In this form, whether simple or forming part of a general arterio- sclerosis, extreme measures, either hot or cold, are usually con- traindicated since the increase of blood pressure which both produce may determine an apoplexy. However, in some cases of chronic nephritis accompanying obesity the most vigorous sweating measures followed by vigorous hot and cold sprays and douches are taken with benefit and marked reduction in blood pressure. Mild diaphoresis is beneficial and this may be secured by short hot baths or the prolonged warm bath at a temperature of 98° or 99°. This tends to equalize the blood pressure and helps to relieve the nerve tension which is a part of the clinical picture in many of these cases. S58 SYSTEMIC AND METABOLIC DISEASES It has recently been shown that the endogenous uric acid in the blood in interstitial nephritis varies according- to the functional activity of the kidneys." These observations were made on a purin-free diet. This retention of uric acid is very favorably influenced by exercise and hydrotherapy. Umber noticed that on a purin-free diet the elimination of uric acid decreased after exercise, owing to its participation in the in- creased oxidation incident to muscular exertion. That like re- sults may be obtained by hydrotherapy has been shown by the researches of Strasser. UREMIA AND ECLAMPSIA These pathologic states, while not identical, have many points in common. In uremia, there is, in the majority of cases, a retention of toxic urinary products because of the kidney insuf- ficiency. While all observers are not agreed as to the constant occurrence of kidney insufficiency in eclampsia, yet nearly all agree that its manifestations are accompanied by a severe poison- ing from some autotoxic source. Croftan says there is much chemical and clinical evidence to show that in uremia the gen- eral metabolism and, in particular, the manifold functions of the liver, are perverted. The kidney may not be primarily involved and possibly in some few cases not at all. In the majority of cases, however, there are demonstrable lesions in the kidney as well as functional inadequacy during life. A great variety of conditions have been reported, among which are infarcts, acute and chronic congestion, edema, greatly increased tension, and actual nephritis. In a case of eclampsia reported by Wiemer 15 the tension was so marked that the kidney substance bulged out on incision in the course of Edebohl's operation. Braak and Mijnlieff 16 report a case in which the right kidney was much enlarged and so painful that the patient, in coma, reacted when it was palpated. They report thirteen other cases 14 In gout the endogenous uric acid in the blood is more constant and never exceeds a certain maximum amount (about 0.003 per cent). A demonstrable amount of uric acid is always present in the blood in gout, even when the food has been free from punns for weeks or months, while blood from normal individuals on a purin-free diet contains no uric acid.— Journal of American Medical Association, April 3, 1909, p. 1110. 15 Monatschrift fur Geburtsh und Gynakologie, March. 1908. 16 Centralblatt fflr Gynakologie, October 19, 1908. UREMIA 359 of eclampsia accompanied by increased tension in the kidney. All were treated by decapsulation and, with one exception, recovered. Franck reports ten cases with no bulging or increased intracapsular tension. Hepatic changes are almost universally present. In fact, functional and structural alterations of the kidneys and liver are very frequently associated. Their functions are consecu- tive, i. 68 TECHNIQUE are used in giving these treatments. They possess such a wide range of adaptability that almost any desired effect may be .produced by them. For this reason both the physician and the nurse should become thoroughly proficient in the use of the spray and douche controller. For a description of the con- troller, see the section on hydrotherapeutic apparatus also Plate L and Figs. 67, 72. 9 Shower Bath — Sh. A shower or rain bath consists in the projection of water in many fine streams falling upon the patient. In the shower bath gravitation is the principal force utilized; the effect, how- ever, is often enhanced by added pressure. The perforated disc from which the water descends should be about eight inches in diameter and from ten to sixteen inches above the patient's head. There should be sufficient force to cause the water to flow rapidly. The room should be very small and protected from drafts. See that the patient's feet are warm before entering the shower. If the wetting of the hair is objectionable, as with women, protect by a rubber or mackin- tosh cap, or with a shower head attached by a ball joint turn it forward at an angle of forty-five degrees. Turn on the shower and adjust to the proper temperature before the patient enters. 1. Hot Shower— H. Sh. Begin the hot shower at 100°— 105° F., and gradually raise the temperature to from 110° — 115° F., or slightly above. Time, one to five minutes. It is used chiefly as a preparation for the cold shower or douche. It may be necessary to use a cold compress to the head during the hot shower. If only a hot shower is prescribed, cool rapidly to 90° or 85° F., and dry quickly with sheet and towels, finishing by fanning the patient with a dry sheet. 2. Cold or Cool Shower — C. Sh. The cold shower is usually preceded by a hot shower. When the patient has been warmed, lower the temperature rapidly from hot to the limit of tolerance or reactive ability of the patient and maintain at this point long enough for a vigorous tonic effect. Those who have become accustomed to cold treatment may take the cold shower PLATE L. Hydrotherapy control table devised by the author. SPRAYS AND DOUCHES 469 without the preliminary hot shower. Cool, 70° — 90° F.; cold, 55° — 70° F. At first, before the patient becomes accustomed to the shower, the upper limits should be utilized and in each succeeding- treatment the temperature lowered by 1° or 2° daily and the time prolonged to from one-half to three or more minutes. Effects, tonic. 3. Neutral Shower — Neut. Sh. In giving- a neutral shower, begin with the water at 100° F., and very gradually lower it to 97° — 94° F. The treatment should last from three to five min- utes. The patient should be dried quickly without percussion or unnecessary friction. Effects, sedative. 4. Graduated Shower — Grad. Sh. After a prolonged or vigorous sweating bath where much heat has been communi- cated to the body, it is desirable to lower the temperature of the shower slowly for gradual cooling and to abstract as much heat from the body as possible without producing a decided thermic reaction. Apply a cold compress to the head before the patient leaves the hot bath. Begin at 108° — 110° F., quickly raising the temperature to 115° or 118° F. Maintain this until the patient feels well warmed and is ready to welcome the cold. Gradually lower the temperature to between 80° and 90° F. , maintaining- it at this point for from two to four minutes. Dry as quickly as possible with sheets and towels and see that the patient is not exposed to cold air or drafts for at least an hour after. 5. Revulsive Shower — Rev. Sh. Begin the shower at 105°- 108° F. and gradually raise the temperature to from 110° — 115° F. or slightly above; continue at this point for one to two min- utes. When the patient has been thoroughly warmed, turn the mixer quickly to cold at a temperature of 60° — 85°. After five to ten seconds turn the mixer valve back to the former tem- perature for one to two minutes. Three complete changes from hot to cold are made. After the last cold, dry quickly with sheets and towels as usual. Effects. The revulsive shower has a mild tonic and stimulant effect. The patient should become accustomed to it before taking the alternate hot and cold shower. The chang-e from 470 TECHNIQUE one to the other may be made gradually by lengthening the duration of the cold with each succeeding treatment. 6. Alternate Hot and Cold Shower — H. & C. Sh. To obtain the best results the changes should be abrupt from hot to cold. As the water must traverse about fifteen feet of pipe before it reaches the patient, an absolutely instantaneous change is im- possible. Beg-in with the hot at a temperature of 106° — 110° F., raising" the temperature quickly to the limit of tolerance and continue it about one minute; then turn the mixer valve quickly to cold and continue fifteen to thirty seconds. Reverse again to hot for about one minute and follow this by a second cold and so on for three complete changes of hot and cold, finishing with the cold and drying as usual. Effects. The alternate hot and cold shower is a vigorous tonic and stimulant. It should not be ventured upon without con- siderable preliminary training by milder measures. Some find it more agreeable than the spray and easier to react to. Sprays — Spr. A spray bath consists in the simultaneous projection of water against all parts of the body by horizontal jets surrounding the patient. For this purpose four upright pipes, arranged in a square and having perforations on the side of each toward the center, are used. Since these pipes are stationary, it is neces- sary to have a short patient stand on a stool so that the water may not strike the face. A tall patient must bend the knees in order to have the spray cover the entire trunk. To overcome this inconvenience and to spread the streams of water still more, .four rosettes may be arranged along each pipe at inter- vals of sixteen inches, the upper row being moveable. The effects and uses of the spray are the same as those of the shower, with the possible difference that the application is some- what more general and there is more or less mechanical stimu- lation due to percussion or pricking of the jets. This is greater as the pressure is increased by the full opening of the spray valve. However this depends entirely on the size of the open- ings in the pipes or rosettes. If many and very fine the treat- ment is most agreeable. Hot, cold, neutral, graduated, revul- SPRAYS AND DOUCHES 471 sive and alternate treatments are given in the same manner as with the shower. Douches — D. The douche is a local application consisting: of a single or multiple column of water directed against some part of the body. It is certainly one of the most useful of all hydrothera- peutic measures. The effect of almost every other form of treatment commonly given to ambulatory patients may be approached and usually exceeded by the douche in the hands of one skilled in its application. The necessary attachments are not numerous. {Figs. 70, 71.} These should consist of a straight nozzle; a spray nozzle or rosette like the sprinkler of a watering pot except that the perforated dish should have a nearly flat face; a fan douche nozzle, a movable flat piece attached to the straight nozzle will answer the same purpose; a stool with an open seat and attached up-shot spray douche nozzle for administering the perineal douche. The jet nozzle is used whenever percussion effects are desired. The pressure may be increased by opening wide the douche valve, or by turning into the nozzle compressed air from a separate tube. Where a percussion douche (Perc. D.) is ordered, the jet is understood. Both cold and percussion pro- duce a decided thermic reaction and increase the vigor and permanency of the circulatory reaction. The spray douche is useful where percussion is not desirable. The jet douche may be ' ' broken ' ' by placing the finger so as to interfere with the stream. It then resembles the spray douche in effect. The effects in general vary according to the mass, pressure and temperature of the column of water striking the body. In prescribing douches the form of nozzle desired should be specified and such designations used as will indicate the part of the body to be treated. The cerebral circulation will be steadied and better general and local results obtained if all applications of the douche begin and end with the feet. The patient should dip the hands in cold water and bathe his face and head before the douche is applied. In applying the douche some definite plan should be learned and systematically followed, 472 TECHNIQUE making; changes when necessary for the particular case and condition in hand. In order to guard against burning, if pos- sible, keep the index finger of the hand holding the douche in contact with the stream of water as it emerges from the nozzle. This should be done with the most perfect of appli- ances and even when no trouble at all is anticipated. Keep a steady hand, apply the douche accurately to the part to be treated and have the thermometers under constant observation. The following are the general directions for douches of dif- ferent temperatures. In giving these any form of nozzle may be used and any portion of the body treated. To enumerate all the possible variations and the particular surface to be treated together with the reflex or hydrostatic effects derived from each would require a small volume in itself. As in all hydrothera- peutic procedures, practical instruction is of far more value than any amount of text description and text illustration. Such designations as the Scotch douche, Charcot douche, etc., are non-descriptive and as far as possible should be dropped from hydrotherapeutie nomenclature. In giving douches it is essential that the changes be abrupt from hot to cold. This is best secured by two douche units each with its own mixer so that both may be kept going during the entire treatment, the changes being made by using the two alternately. In this way the changes are absolutely instantaneous. The following types serve only as a general guide. The successful physician will find use for many grada- tions between the revulsive and alternate hot and cold douche. The treatment must be adapted to each individual case. 1. Hot Douche — H. D. Where the hot douche alone is used it is given for a relatively long time, two to five minutes, at a temperature of 105° — 125° F., and followed by a very brief application of cold, five to fifteen seconds; temperature 60°- 90° F. This is supposed to be just long enough to remove from the skin the heat communicated by the hot douche. The principle is identical with that of the revulsive douche except that in the latter, three or more changes are employed, while here only one is given and the duration is much longer. Effects. The hot douche produces dilatation of the cutaneous SPR A YS AND DO UCHES 473 vessels and so where applied to a considerable area, effective derivation is secured. Where applied to a small area, the dila- tation of the vessels in the deep part through a reflex channel may equal or exceed the hydrostatic effect. Percussion intensi- fies the reflex effect. The hot douche is used for the relief of pain, irritation, neuralgia, sciatica, etc. In these cases per- cussion is undesirable. 2. Neutral Douche — Neut. D. Temperature, 94° — 97° F.; time, three to six minutes. The broken jet or spray douche is used since sedative effects are sought. The neutral spray douche is especially beneficial when given to the spine. No force should be used and the patient should sit on a stool with the back to the operator. If given properly this treatment is essentially a neutral pour. 3. Cold Douche— C. D. Temperature, 55°— 70° F. The cold douche is seldom given alone, but when not preceded by hot, the percussion jet should be used. Given in this way, vigorous fluxion is produced in the part treated with a corres- ponding derivation from other parts. For this reason it is very effective in relieving cold feet. 4. Revulsive Douche — Rev. D. Three abrupt changes from hot to cold are used. Temperature of the hot, 112° — 115° F.; time, a half to two minutes; temperature of the cold, 55° — 70° F.; time, five to ten seconds. Unless given with high pressure, (percussion) the reaction is chiefly circulatory. Percussion is not usually desirable with the revulsive douche. Effects. It will be noted that the duration of the cold is exceedingly brief as compared with the duration of the hot. In this item lies the difference between the revulsive and the alter- nate hot and cold douche. The effect of the re vulsive douche is chiefly circulatory and greater in the surface blood vessels than in the deep part, i. ikilothermic animals, 28 Poisoning, ivy, 232 systemic, 342 Poultices, 397, 417 Prescription writing, 490 Properties of water, 17 Proctoclysis, Murphy method, 482 absorption of fluid, 93 in surgical collapse, 383 Prostatic hypertrophy, 493 Prostatitis, 258, 475 Proximal application, 74, 410 Psychic attitude, effect on reac- tion, 36 Puerperal infection, 214, 254, 460 Pulmonary congestion, 214, 333 hemorrhage, 371 Purin, diathesis, 343 a cause of fever, 161 as fatigue poison, 136, 138 effects of coffee on, 360 effect of cold on, 116 in gout, 343 Pyrexia, see fever Quassia, enema, 486 Quinin, enema, 486 in fevers, 169 in malaria, 194, 199 in pneumonia, 239 prophylactic use of, 195, 197 protozoan immunity to, 197 Radiant heat, 408 Radiation, heat loss by, 141 Reaction, 30 ability, test of, 37 circulatory, 33, 49 conditions influencing, 35 deep reflex, 73, 76 incomplete, 34 in blood vessels, 49 in malaria, 204 nervous, 33 of short cold, 31 phases of, 33 rationale of, 31 repeated 34 suppressed, 34 thermic, 33 time factor in, 32 to heat, 32 types and degrees of, 34 Rectal injection, see enemata . irrigation 479 tenesmus, 322 ulcer, 319 Red cells, effect of cold on, 100 effect of heat on, 102 Reflex arc, 65 areas, 64, 69 effects, 62 classes, 72 Refrigerants, in fever, 170 Resistant gymnastics, 289 Respiration, 125 by skin, 59 Rest, in heart disease, 285 Retrostasis, 80 Revulsion, defined, 217, 399 Revulsive compress, 405 douche, 473 pack, 457, 458 sitz bath, 435 Rheumatic fever, 247 Rheumatism, chronic gouty, 278, 343 with emaciation, 348 with obesity, 347 Risley, experiments of, 122 Romberg and Passler, researches of, 165, 188, 236 Rubner, chart on heat loss, 143 experiments of, 128 Rubs alcohol, 424 cold towel, 263, 420 in typhoid, 184 dripping sheet, 263, 421 dry, 430 ice, 184, 422 menthol, 425, oil. 428 vinegar and salt, 424 wet hand, 262, 420 wet sheet, 263, 421 witchhazel, 425 Rubs and frictions, 398, 425 Russian bath, 447 Russian bath room, 502 Saline bath, 443 sponge, 424 Salpingitis, 214, 254, 460 492 Salt and vinegar rub, 424 Salt glow, 263, 422 Salt, relation to edema, 352 Scarlet fever, 206 Srhott treatment, 289 Schuller, experiments of, 62, 78 Sciatica, 215, 321, 474 INDEX 519 Sebaceous glands, 58 Sedative effects, 72, 300 Sedatives, general, 301 local, 304 pure, 300 tonic, 303 Septicemia, 230 Serum, Flexner's, 251 Shampoos, 398, 452 Sheet pack, 461 in typhoid, 184 Sheet rub, wet, 263, 421 dripping, 263, 421 Shock, surgical, 376 Shower bath, see sprays Sinsuoidal electricity, in neuras- thenia, 274 tub bath, 441 Sitz bath, 434 Sitz tubs, 501 Skin, 39, 54 heat, regulation by, 60 respiration by, 59 vicarious functions of, 56 Soap suds enema, 483 vaginal irrigation, 488 Soap wash, 425 Specific heat, 20 Spinal paralyses, spastic,311, 475 Splanchnic efferent nerves, 66, 72 neurasthenia, 273 Spleen, effects on distribution of blood cells, 103 Sponging, 397, 423 Sprains, 326 Sprays, 398, 467, 470 Starch, enema, 485 Starling, work of, 92 Steam boxes, 400, 499 Steam inhaler, 334 Stimulant effects, 72, 260, 295 Stimulants, 260 drug, defined, 260 intestinal, 298 uterine, 297 vesical, 297 Stimuli, mechanical, 23, 129 thermic, 22 Stomach, reflex arc to, 68 Stupes, 404 Strychnin, as a general tonic, 137 in pneumonia, 240 in surgical shock, 387 in typhoid, 188 Sulphates, effect of cold on, 120 5X0 INDEX Sun baths, in anemia, 268 in neurasthenia, 272 Sunstroke, 282 Surgery, after-treatment, 389 hydrotherapy in, 373 immediate care, 375 preparatory treatment, 373 relation to physiologic ther- apy, 156 Surgical shock, 376 contributing causes, 377 drugs in, 385 hydrotherapy in, 383 treatment of, 382 Sweat glands, 54 in nephritis, 57 perspiratory influences, 57 vicarious functions, 56 Swedish shampoo, 452 Talcum rub, 430 Technique of hydrotherapy, 397 classification, 397 glossary of terms, 398 Temperature, common names of, 38 nerves of, 61 Tenesmus, 322 Therapeutics, 155 Therapy, basic principles of, 159 physiologic, realm of, 155 principles of, 27 Thermic stimuli, 22 Thermometers, 19 Thermotherapy, 17, 27 Throat compress, heating, 416 Tobacco blindness, 227 Tonic effects, 32, 260 frictions, 397, 418 sedatives, 303 Tonics, hydriatic vasomotor, 288 Tonsillitis, 229 in scarlet fever, 20 Tonus waves, 48 Towel rub, see rubs Tracoma, 226 Traube-Hering waves, 46, 379 Trauma, relation to shock, 377, 388 Trunk pack, heating, 464 hot, 457 Tuberculosis, pulmonary, 275 Turkish bath, 449 shampoo, 453 Turpentine enema, 484 Tympanites, in typhoid, 192 Typhoid fever, 179 hot treatment in, 186 cold treatment of, 180 Ulcer, duodenal, 319 gastric, 319 rectal, 319 trophic, 494 varicose, 474, 494 Urea, effect of cold on, 115 in uremia, 359 Uremia, 358, 493 acute, 361 Urethritis, specific, 258, 475 Uric acid, effect of caffein on, 360 effect of cold on, 116 effect of heat on, 121 endogenous, in gout, 358 formation and destruction of, 344 Vaginal irrigation, 398, 486 Vaginitis, 258 Valvular heart disease, 283 Vapor bath, 448 Varicose ulcer, 474 Vasomotor center, 62, 66 paralysis of, in fevers, 165 in shock, 379 Vasomotor nerves, 41, 44, 62 Vasomotors, effect on blood vessels, 44, 62 failure in fevers, 165 in shock, 379 in typhoid, 188 Vasomotor tonics, in fevers, 167 in heart disease, 286 in surgical shock, 383 Veno-pressor mechanism, 380, 381 Vesical stimulants, 297 tenesmus. 322 Vibration, in heart disease, 288 Vinaj and Maggiori, experiments of, 130 Vinegar and salt rub, 424 Vinegar vaginal irrigation, 489 Viratrum viride, in fevers, 168 Vomiting, 494 Warm-blooded animals, 28 Water, expansion of, 18 mineral, 25. 345, 348 INDEX 521 properties of, 17 in typhoid, 184 Water bottles, hot, 407 Wet sheet rubs, 263, 421, see Water drinking, cold, effect on rubs blood pressure, 98 White cells, see leucocytes effect on urea excretion, 121 Win,.ernitz coil, 407 in dysnepsia, 366 in dyspepsia, 365 in pneumonia, 239 in typhoid, 185 in surgery, 375, 391 Winternitz pack, 407, 466 Wet hand rub, 262, 420, see rubs in dyspepsia, 365 Wet sheet pack, 461, see packs Witchhazel rub, 425 Date Due PRINTED IN U.S.*. CAT. NO. 24 161 A 000510244 7 WB520 A131p Abbott, George Knapp. Principles and practice of hydrotherapy 3 S WB520 A131p Ab£f. George Khapp. W14 "^ ~ SU. of ^^ MEDICAL SCIENCES LIBRARY UNIVERSITY OF CALIFORNIA M IRWNE, CflUFORNIfl 92664